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Prior Review and Limitations

Some drugs require more than a provider's prescription in order to be covered by BCBSNC.

This page provides details regarding the following:

  • What You Need To Know: General information regarding your plan and associated formulary (i.e., drug list)
  • Utilization Management: Your provider may need to give BCBSNC additional information for you to receive specific drugs under your benefits. This allows all of us to work together to provide you with the safest, most effective and cost-efficient drugs.
  • Drug Benefit Limitations: Some drugs are subject to specific limitations.

What You Need to Know:

Your benefit plan and formulary

Your benefit plan and the associated formulary, or drug list, will help you determine which requirements apply to you when accessing your pharmacy benefits. The type of plan you have is printed on the front of your member ID card. Your ID card also identifies the type of formulary, or drug list, with an Rx and a letter on the bottom-right corner of the card. These letters represent a formulary, or drug list, as follows:

Rx A, B, E, F = Enhanced Formulary
(both Enhanced 4 and Enhanced 5 tier plans have the same requirements below)
Rx C = Basic Closed Formulary
Rx D = Basic Open Formulary

Accessing Your Formulary

You can access your formulary, or drug list, by taking the following steps:

Step 1: Go to and sign into Blue Connect. Blue Connect will display your specific benefits and formulary.

Step 2: Click on "Prescriptions;" the first section is "Find a Drug." Once you click on the link it will take you to our pharmacy benefit manager's website. Once there, your formulary name will be displayed.

Step 3: Enter the drug name and dosage information, and the section below the cost will tell you if review requirements, such as prior review, apply. If such requirements are listed, this means your provider needs to give us additional information before the drug will be approved. Definitions of possible terms you might see are located here.

Utilization Management

Some drugs need additional information from your provider before BCBSNC will cover them. A list of these drugs is provided below. While we try to keep this list up-to-date, this list changes due to new drugs coming to the market. In order to know for sure if these requirements apply to a particular drug, search the formulary for the specific drug name in question. The requirements for approval will be listed under the criteria of each drug listing. For steps on how to access your formulary see What You Need To Know.

If a drug on the Basic Open Formulary indicates a requirement for prior review and step therapy (PA, ST) but is not in the list of drugs below, please have your provider use this criteria. If you meet the criteria, have your provider submit the completed form to the fax number on the bottom of the form.

Some drugs are not included on the Basic Closed Formulary. If a drug is not listed under "Find a drug" for the Basic Closed Formulary and another drug cannot be used in its place, please use this criteria. If you meet the criteria, have your provider submit this completed fax form to the fax number on the bottom of the form.

PLEASE NOTE: If you change benefit plans, your provider may need to verify again that you have met our clinical criteria under that new policy.

Drug Search

Search by drug name:
Or click the first letter of your drug to view lists:

To find a drug, use the search above or select a letter from the list above.

Brand Drug Name: {{header}}

  • Generic Drug Name:
  • Benefit: ,
  • Specialty:
  • Prior Review Required On: ,
  • Prior Review Required:
  • Quantity Limits Required On: ,
  • Quantity Limits:
  • Restricted Access/Step Therapy On: ,
  • Restricted Access/Step Therapy:
  • Non-formulary Exception Review Required On: Basic Closed Formulary
  • Criteria: ,
  • Fax Form: ,
  • Note:

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Explanation of terms in Drug Search

  • Criteria - This tells you what conditions must be met for you to receive the specific drug under your BCBSNC benefit. Some of this may be technical medical information, but it's here for you to read and be able to discuss with your provider.

  • The different types of review:

    • Prior Review (PA)*: Providers will need to review BCBSNC clinical criteria and verify that you meet the requirements so they may receive the drug prescribed.

    • Quantity Limitations (QL)*: Providers will need to review BCBSNC clinical criteria and verify that you meet the requirements so they may receive the total amount prescribed. You can still receive the medicine without BCBSNC review and approval, just not over a set amount.

    • Restricted Access/Step Therapy (RA/ST)*: Providers will need to confirm that you have tried specific, non-restricted medicine(s) first and that it was ineffective or harmful to you in the past (and the provider believes it will be ineffective or harmful again) before you can receive the other, non-restricted medicine.

    • Nonformulary Exception: This type of review only applies to members on the Basic Closed formulary. Providers will need to (1) determine that the nonformulary drug is medically necessary and appropriate for your condition; (2) notify BCBSNC that you have tried drugs available on the formulary and that they were ineffective or harmful in the past (and the provider believes they will be ineffective or harmful again); and (3) prescribe the drug in accordance with applicable BCBSNC clinical protocol or have it be approved as an exception through BCBSNC's exception process.

      The benefits for any nonformulary exception approvals will be as follows:
      • Generic drugs will be subject to tier 2 non-preferred generic benefit
      • Brand-name drugs will be subject to tier 4 non-preferred brand-name benefit
      • Specialty drugs will be subject to tier 5 specialty drug benefit

  • Specialty drugs*: Drugs classified by BCBSNC which generally have a unique indication or use, require special dosing or administration, are typically prescribed by a specialist, or are significantly more expensive than alternative therapies. These drugs are limited to a 30-day supply and must be obtained through an in-network specialty pharmacy in order to receive in-network benefit. In-network pharmacy options will vary based on your plan specific benefits.

*For more information and plan definitions, please see "Covered Services" and "Glossary" in your benefit booklet.

Submitting Requests to BCBSNC

You may start a request for a drug by phone, or by downloading a fax form by searching for it in the Drug Search section. However, in order for the review process to be completed, your provider must give all necessary information on each fax form, including their signature. We have found the most efficient way to accomplish this is for your provider to submit the forms directly to us. This can be done in the following ways:

Electronic (preferred): We have teamed with CoverMyMeds to offer electronic review submissions, which allows for fast processing, and for some drugs to be immediately determined. If a drug is approved through the system, the pharmacy will have your authorization in less than 2 hours.

Fax: They can fax a completed copy to us. Faxes can be sent to the fax number on the bottom of the form, or 1-800-795-9403.

Once BCBSNC has all information to make a decision, your provider will hear back from us within three business days. If there are questions about submitting a review, or its status, we can be reached at 1-800-672-7897.

Drug Benefit Limitations

Drug Type Benefit Limit
Hypnotics ("sleeping pills," e.g., Ambien®, Lunesta®, Sonata®, Zolpidem, Intermezzo) Individual & family plans and Underwritten groups: No limit
Self funded / ASO groups: Refer to member guide or contact Customer service
Infertility Drugs For groups which in 2013 had a $5000 lifetime maximum and were able to carry this over due to updates to the Affordable Care Act, this benefit will remain available. Otherwise, the benefit is as follows (call Customer Service to confirm):

Underwritten and Individual/Family plans:
Infertility drugs are limited to the following lifetime maximum per member:
  • Follitropins (e.g. Bravelle, Follistim, Follistim AQ, Gonal-F) (3000 units)
  • Oral ovulation stimulants (Clomid) (360 tablets)
  • Subcutaneous injectable ovulation stimulants (e.g. Ovidrel) (1,000 micrograms)
  • Subcutaneous injectable ovulation stimulants (e.g. Luveris) (1500 units)
  • Intramuscular injectable ovulation stimulants (e.g. Novarel, Pregnyl) (40,000 units)
  • Menotropins (e.g. Repronex, Menopur) (1500 units)
  • Gonadotropin-releasing hormone antagonists (e.g. Cetrotide, Ganirelix) (3mg)
  • Progestins(e.g. Crinone gel) (104.4mg)
  • Progestins(e.g. Progesterone suppositories, Endometrium suppositories) (90 units)
Self funded / ASO groups:
Call customer service to confirm
Sexual Dysfunction Drugs Related to Organic Disease (e.g., Cialis®, Viagra®, Caverject®) Underwritten and Individual / Family plans:
4 tablets or units per 30 days
Self funded / ASO groups:
Call customer service to confirm
Sexual Dysfunction Drugs Unrelated to Organic Disease All:
Not covered
Smoking Cessation Drugs Individual & family plans and Underwritten groups: No limit
Self funded / ASO groups: Refer to member guide or contact Customer service