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Prior Approval and Quantity Limitations



Prior Approval

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

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

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

Drugs Requiring Prior Approval Utilization Management Criteria Physician Fax Request Form
Growth Hormones All Growth Hormones Call 1-800-672-7897 for prior approval
Insulin-like Growth Factors All Insulin-like Growth Factors Call 1-800-672-7897 for prior approval
Cox 2 Inhibitors
(e.g. Celebrex®)
All Cox 2 Inhibitors Use Cox 2 Fax Request Form
Antifungals
(Lamisil®, Sporanox®)
Antifungals Use Antifungal Fax Request Form
Disease Modifying Antirheumatic Drugs
All Botulinum Toxins FDA approved conditions Call 1-800-672-7897 for prior approval
Antipsoriatics
Respiratory
(Xolair®)
Xolair® Use Xolair® Fax Request Form
Orencia®
Remicade®
Rituxan® (for Rheumatoid Arthritis ONLY)
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 approval
Transmucosal Fentanyl


Restricted-Access Drugs

The nonpreferred drugs listed below are considered restricted-access drugs that require an initial physician certification prior to being covered.

Restricted-Access Drug Classes Nonpreferred drugs Physician Fax Request Form
Proton Pump Inhibitors (PPIs) (updated 11/09)
  • Aciphex®
  • 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 approval 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 approval process.

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

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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.