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Prior Review and Quantity Limitations


Prior Review

Some medications require prior review from BCBSNC before the prescription can be accepted for payment.

Blue CareSM, Blue OptionsSM, Blue ChoiceSM, and Blue AdvantageSM

Prior review requires that your physician contact BCBSNC at 1-800-672-7897 or fax a request form to 1-800-795-9403.

Drugs Requiring Prior Review Utilization Management Criteria Physician Fax Request Form
Growth Hormones All Growth Hormones Call 1-800-672-7897 for prior review
Insulin-like Growth Factors All Insulin-like Growth Factors Call 1-800-672-7897 for prior review
Cox 2 Inhibitors
(e.g. Celebrex®)		 All Cox 2 Inhibitors Use Cox 2 Fax Request Form
Naproxen / esomeprazole
(Vimovo®)
(effective 10/1/10)		 Vimovo Vimovo - effective 10/1/10
Antifungals
(Lamisil®, Sporanox®)		 Antifungals Use Antifungal Fax Request Form
Disease Modifying Drugs for Multiple Sclerosis (MS)
(effective 10/1/10 for new users)
- Betaseron®
- Extavia®
- Avonex®
- Rebif®
- Copaxone®		 Disease Modifying Drugs for MS Disease Modifying Drugs for MS - effective 10/1/10 for new users
Potassium Channel Blocker
(Ampyra®)
(effective 10/1/10)		 Ampyra Ampyra - effective 10/1/10
Disease Modifying Antirheumatic Drugs (DMARD)
- Actemra®
- Orencia®
- Remicade®
- Rituxan® (for Rheumatoid Arthritis ONLY)
All Botulinum Toxins FDA approved conditions Call 1-800-672-7897 for prior review
Antipsoriatics
Respiratory
(Xolair®)		 Xolair® Use Xolair® Fax Request Form
Intravenous Immune Globulins (IVIg)
(Effective 1/1/2010)
- Carimune NF
- Flebogamma
- Flegogamma DIF
- Gammagard Liquid
- Gammagard S/D
- Gamunex
- Octagam
- Privigen
Subcutaneous Immune Globulins (SCIg)
(Effective 1/1/2010)
- Vivaglobin		 IV and SC immune globulin Call 1-800-672-7897 for prior review
Transmucosal Fentanyl
Respiratory Syncytial Virus (RSV) Prophylaxis: Palivizumab (Synagis®)
(effective 7/1/2010)
Oral Drugs for Pulmonary Arterial Hypertension (PAH)
(effective 10/1/10 for new users)
- Tracleer®
- Letairis®
- Revatio®
- Adcirca®
  • Oral Drugs for PAH - effective 10/1/10 for new users
Antinarcoleptic Agents
(effective 10/1/10)
- Provigil®
- Nuvigil®
  • Antinarcoleptic Agents - effective 10/1/10
Cyclosporine ophthalmic emulsion (Restasis®)
(effective 10/1/10 for new users)
  • Restasis - effective 10/1/10 for new users
Sipuleucel-T (Provenge®) Cellular Immunotherapy for Prostate Cancer
Collagenase clostridium histolyticum (Xiaflex®) Injectable Clostridial Collagenase for Fibroproliferative Disorders


Restricted-Access Drugs

For the nonpreferred prescription drugs listed below, BCBSNC requires that the member has tried a preferred drug or device. Coverage for these prescription drugs may be provided without the use of a preferred drug or device if the provider certifies in writing that the member has previously used a preferred drug or device and the preferred drug or device has been detrimental to the member's health or has been ineffective in treating the same condition and, in the opinion of the provider, is likely to be detrimental to the member's health or ineffective in treating the condition in the future.

Restricted-Access Drug Classes Nonpreferred drugs Physician Fax Request Form
Angiotensin Receptor Blockers (ARBs) - (effective 7/1/10)
  • Atacand®
  • Atacand HCT®
  • Avapro®
  • Avalide®
  • Benicar®
  • Benicar HCT®
  • Teveten®
  • Teveten HCT®
 Use Restricted-Access Drugs Request Form.
Requests DO NOT need to be submitted for the preferred ARBs losartan, losartan/HCTZ, Diovan, Diovan HCT, Micardis, and Micardis HCT.
Tetracyclines (effective 10/1/10)
  • Doryx®
  • Solodyn®
 Tetracyclines - effective 10/1/10.
Requests WILL NOT need to be submitted for the preferred tetracyclines doxycycline/hyclate (generic) and minocycline (generic).
Proton Pump Inhibitors (PPIs) (updated 11/09)
  • Aciphex®
  • Dexilant™ (Kapidex™)
  • Lansoprazole Powder (for pharmacy
    compounding only; doesn't include
    Prevacid brand products)
  • Prevacid® SoluTabs; granules for suspension
  • Prilosec® for oral suspension
  • Protonix® 40mg Suspension
  • Zegerid®
 Use Restricted-Access Drugs Request Form
Requests DO NOT need to be submitted for the preferred PPIs omeprazole, pantoprazole, lansoprazole, and Nexium-®
Intranasal Steroids (effective 10/1/09)
  • Beconase AQ®
  • Nasacort AQ®
  • Omnaris®
  • Rhinocort Aqua®
  • Veramyst®
 Use Restricted-Access Drugs Request Form
Requests DO NOT need to be submitted for the preferred intranasal steroids flunisolide, fluticasone propionate, or Nasonex.
Oral Bisphosphonates (effective 10/1/09)
  • Actonel®
  • Actonel® with Calcium
 Use Restricted-Access Drugs Request Form
Requests DO NOT need to be submitted for the preferred bisphosphonates alendronate, Fosamax Plus D, or Boniva.
Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants (effective 4/1/10)1
  • Lexapro®
  • Luvox CR®
  • Pexeva®
 Use Restricted-Access Drugs Request Form
Requests DO NOT need to be submitted for the preferred SSRIs citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline.
Drugs for Migraines (Triptans) (effective 4/1/10) Quantity Limitations may also apply to all triptans. See Quantity Limitations below.
  • Amerge®
  • Axert®
  • Frova®
  • Sumavel™ DosePro™
  • Treximet®
  • Zomig, Zomig ZMT®
 Use Triptans Fax Request Form
Requests DO NOT need to be submitted for the preferred Triptans sumatriptan, Maxalt/MLT, and Relpax.
Hypnotic Agents (effective 4/1/10) A benefit limit may apply to hypnotic agents.
  • Ambien CR®
  • Edluar®
  • Lunesta®
  • Rozerem®
  • Zolpimist®
 Use Restricted-Access Drugs Request Form
Requests DO NOT need to be submitted for the preferred Hypnotic Agents zaleplon and zolpidem.

1Certification is not required for patients already taking a nonpreferred SSRI antidepressant (prescription claim within the past 12 months).

Quantity limitations

BCBSNC covers certain medications up to a set quantity. Quantity limitations are designed to help identify excessive usage of drugs.

If a physician feels it is medically necessary to exceed quantity limitations on your medication, they must get prior review from BCBSNC at 1-800-672-7897 before a higher quantity will be covered.

The following is a list of drugs with quantity limits:

Drugs with Quantity Limits Utilization Management Criteria Physician Request
Triptans Use Triptans Fax Request Form
Quantity limit requests need only be submitted for members to get MORE than the allowable amounts listed.
Transmucosal Fentanyl Transmucosal Fentanyl Fax Form
Quantity limits only apply if transmucosal fentanyl is approved through the prior review process.

Benefit Limits

Certain medications have set quantity limits per days supply that are not available for physician override but are set supply limitations per a member's plan benefit. The following list contains standard benefit limits. Some groups may have different amounts according how the specific benefit was designed.

Drug Type Benefit Limit
Hypnotics ("sleeping pills," e.g., Ambien, Lunesta, Sonata, zolpidem) 20 tablets or capsules per 30 days*
Infertility Drugs $5,000 lifetime maximum
Sexual Dysfunction Drugs (e.g., Cialis, Viagra, Caverject) 4 tablets or units per 30 days
Smoking Cessation Drugs 1 treatment episode per year, 2 treatment episodes per lifetime*

To learn more about prior review or quantity limitations for enrolled federal and state employees, please visit the Federal Employee Plan site or the State Health Plan site.

* This standard benefit limit no longer applies for underwritten groups effective July 1, 2010 (regardless of the group's renewal/effective date) due to the Mental Health Parity Addiction and Equity Act (MHPAEA) and associated regulations. Effective July 1, 2010, the standard benefit for underwritten groups will be no benefit limit; however, clinical and safety limits may apply. For self-funded/ASO groups, check your benefit booklet or call customer service to confirm the benefit limit.

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* All services are subject to the allowed amount charge. When using out-of-network providers, any amount charged over the allowed amount may be your responsibility.