Skip Navigation

Prior Review and Limitations

Some drugs require more than a provider's* prescription in order to be covered by Blue Cross NC.

*Doctor, dentist, nurse practitioner, pharmacist practitioner, physician assistant

This page gives details about the following; click on blue terms to take you to a specific section:

What You Need to Know:

Your benefit plan and formulary

Your benefit plan and the associated formulary, or drug list, will help you figure out what requirements apply to you when accessing your pharmacy benefits. Your plan type is printed on the front of your member ID card. You can find your formulary, or drug list, on the bottom-right corner of your card. Look for the Rx and a letter. These letters represent a formulary, or drug list, as follows:

Rx A, B, E, F, G, H, S, T = Enhanced Formulary
(both Enhanced 4 and Enhanced 5 tier plans have the same requirements below. Additionally, both Enhanced Commercial (C) and Enhanced Qualified Health Plan (Q) plans have the same requirements below)
Rx D, J, K = Basic Open Formulary
(both Basic Open Commercial (C) and Basic Open Qualified Health Plan (Q) plans have the same requirements below)
Rx L, M, N, P, U = Essential Formulary
(both Essential Commercial (C) and Essential Qualified Health Plan (Q) plans have the same requirements below)
Rx Q, R, V = Net Results Formulary

Accessing Your Formulary

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

Step 1: Go to bcbsnc.com and sign in to 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, you will see your formulary name.

Step 3: Enter the drug name and dosage information. 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 more information before the drug will be approved. Check here for definitions or terms you might see.

 

Utilization Management

Some drugs need more information from your provider before Blue Cross NC will cover them. Most of these drugs are listed below. We want to make sure that you have the most complete list of requirements. We encourage you to look at your specific formulary, or drug list. For steps on how to find your formulary see What You Need To Know.

The medications listed below under "Drug Search" are the drugs most often used by our members. The information listed will tell you what type of review is required for each formulary. The criteria will tell you when Blue Cross NC will cover the medication under your pharmacy benefits. A fax form will also be listed. This form tells you what information Blue Cross NC needs from your provider to process the medication request.

If you find your formulary states prior review and step therapy (PA, ST) are required for a medication on the Basic Open or Essential Formularies, but the drug is not listed below in the "Drug Search," please have your provider use this criteria. Send information to Blue Cross NC using this fax form.

Explanation of terms in Drug Search

  • Criteria - This tells you what conditions you have to meet for a drug to be covered under your benefits. Some of this may be technical medical information, but it's here for you to read and discuss with your provider.

  • The different types of review:

    • Prior Review: Your doctor will have to tell Blue Cross NC in writing that you meet our medical necessity criteria.

    • Quantity limitations (limits in the amount of medicine your insurance will cover): To encourage appropriate use, Blue Cross NC may set limits on how much medication can be received . This may include decreasing the number of pills taken per day without changing the total amount of medication. For example, moving from two 20 mg pills per day to one 40 mg pill per day. Your doctor will need to tell Blue Cross NC in writing that you meet our medical necessity criteria to get above the set amount.

    • Restricted access / step therapy: Blue Cross NC requires that you first try a drug (or device) that is not restricted before a restricted drug will be approved. You may be covered for a restricted drug if your doctor tells Blue Cross NC in writing that:
      • You have already used the non-restricted drug, and the non-restricted drug was not effective in treating the same condition.
      • Or, if your doctor thinks the non-restricted drug is likely to be harmful to your health or not effective in treating your condition.

    • Nonformulary (NF)*: Providers will need to confirm that you have tried formulary alternatives first and they were ineffective or harmful to you. Also, medication-specific clinical criteria must be met before approval (available in the Drug Search). A nonformulary medication is one that is not included in the list of drugs that are eligible for benefits under your Blue Cross NC plan. Not all formularies have nonformulary drugs.

  • Specialty drugs*: Drugs labeled by Blue Cross NC which generally have/are:
    • A unique indication or use
    • Call for special dosing or administration
    • Typically prescribed by a specialist
    • Significantly more expensive than alterntive therapies

These drugs are limited to a 30-day supply and you must get them through an in-network specialty pharmacy. Using an in-network pharmacy guarantees your benefits will cover the prescription. In-network pharmacy options will vary based on your plan specific benefits.

*Please see "Covered Services" and "Glossary" in your benefit booklet for more information.

PLEASE NOTE: If you change your health plan, your provider may need to tell us again that you have met our clinical criteria under your new plan.


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:
  • Nonformulary on: ,
  • Nonformulary:
  • Criteria: ,
  • Fax Form: ,
  • Note:


No results found for '{{header}}'

Requests for Drugs Not Listed on the Formulary — Essential and Net Results Only

If your provider recommends a drug that is not listed on the formulary (drug list), ask them if there is another medication that is part of your formulary. If not, you can submit a request for a nonformulary exception, which will need to meet this criteria. Some medicines have other utilization management requirements (i.e. quantity limitations). You will still need to meet these requirements even if your nonformulary exception request is accepted. You can request a quantity limit exception when you send your nonformulary exception request.

Your provider must give us all information on the fax form, including their signature, in order for us to review the request. The best way to do this is to have your provider send the form directly to us. Some plans have other options; please read below.

If your ID card shows N, P, Q, R, U or V after the letters Rx, the following formulary exception process would apply:

  • Your provider can follow the instructions under "Submitting Requests to Blue Cross NC" OR
  • You can send us your request as a member, but we will need to contact your provider to get the necessary clinical information to review the request. It is best to work with your provider and figure out the best way to submit a request. We need the following information in order to contact your provider and ask for the needed information:
    • Your name, date of birth, gender and Blue Cross NC ID number
    • The name of the medication you are requesting
    • Your doctor's name and telephone number
    • Your telephone number
  • You can call 800-672-7897 to give us this information and begin your request. You can also mail the above information to:
    • Blue Cross NC
      Attn: Care Management and Operations
      P.O. Box 2291
      Durham, NC 27707
  • When we receive your request, we will contact your provider and get the necessary clinical information. Your doctor has 5 calendar days to give us the necessary clinical information. We will begin handling the request once we have enough information to make a decision, or within 5 calendar days of requesting the information from your provider, whichever is earlier. We will notify your provider of our decision within three business days.

If your ID card shows L or M after the letters Rx, the following formulary exception process would apply:

  • Your provider can follow the instructions under "Submitting Requests to Blue Cross NC" OR
  • You can send us your request as a member, but we will need to contact your provider to get the necessary clinical information to review the request. It is best to work with your provider and figure out the best way to submit a request. We need the following information in order to contact your provider and ask for the needed information:
    • Your name, date of birth, gender and Blue Cross NC ID number
    • The name of the medication you are requesting
    • Your doctor's name and telephone number
    • Your telephone number

    This information could be submitted in the following ways:

    • Call 800-672-7897 to begin your request by phone
    • Fax your request to 800-795-9403
    • Mail us at:
      Blue Cross NC
      Attn: Care Management and Operations
      P.O. Box 2291
      Durham, NC 27707
    • Email PharmacyCoordinator@bcbsnc.com
      Please note: Sending personal information, including about your health, by email via the Internet can be intercepted and read by individuals other than the intended recipient. Using an encrypted email service or other secure means of communication may protect your information from third parties reading your communication. You acknowledge that you understand these risks when you send your email.

  • When we receive your request, we will contact your provider and get the necessary clinical information. Your doctor has 5 calendar days to give us the necessary clinical information.

We will begin handling the request once we have enough information to make a decision, or within 5 calendar days of requesting the information from your provider, whichever is earlier. Regular requests will be handled within 72 hours. Urgent* requests will be handled within 24 hours.

*A request is defined as urgent when, in the prescriber's opinion, a delay would seriously jeopardize the life or health of the patient, the patient's ability to regain maximum function, or would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested.

For all members on Essential or Net Results, if the request of the non-formulary drug is approved, the following tiers and associated benefits (listed in the member's benefit booklet) will apply:
Drug Type and Formulary Tier Assigned to Approved Nonformulary Drug
Non-specialty drug on Essential 5 tier formulary Tier 4
Non-specialty drug on Essential 6 tier formulary Tier 4
Non-specialty drug on Net Results formulary Tier 4
Specialty drug on Essential 5 tier formulary Tier 5
Specialty drug on Essential 6 tier formulary Tier 6
Specialty drug on Net Results formulary Tier 5


Submitting Utilization Management Requests to Blue Cross NC

Utilization Management Requests may include, but are not limited to, prior authorization for a prescription drug or requests for coverage of a restricted access drug or non-formulary drug. As a member, you may start a request for coverage with us directly (either by phone at 1-800-672-7897 or by giving us the information on the fax form and faxing to the number on the bottom of the fax form). Your provider needs to give us all of the information on each fax form, including their signature, before it can be reviewed. The best way to do this is to have your provider send the forms to us.

Providers can turn in requests to us a few ways:

Electronic (preferred): We use CoverMyMeds so providers can submit requests to us electronically. Some drugs if approved can be ready at the pharmacy in less than 2 hours.

Fax: Your provider can send completed forms to the fax number on the bottom of the form, or 1-800-795-9403.

Unless otherwise noted, we will contact your provider within three business days once we have the information we need. You can call us at 1-800-672-7897 to check the status of your review or with any questions.


Drug Benefit Limitations

Please note: not all benefit limits are listed in the table below. Self-funded / ASO group members should refer to their unique member guide or contact customer service for additional benefit limits which may apply to them (e.g. hypnotics, smoking cessation).


Drug Type Benefit Limit
Infertility Drugs For groups that had a $5000 lifetime maximum in 2013 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 8% gel) (101.25g or 90 syringes/applicators)
  • Progestins (e.g. Progesterone suppositories, Endometrium suppositories) (90 units)
Sexual Dysfunction Drugs Related to Organic Disease (e.g., Cialis®, Viagra®, Caverject®) Underwritten and Individual / Family plans:
4 tablets or units per 30 days
Sexual Dysfunction Drugs Unrelated to Organic Disease All:
Not covered
Non-Food and Drug Administration (FDA) Approved Drugs All: Not covered; please see list for specific drugs that are not covered

Reviews on Specific Charges

  • Difference between brand and generic drugs - depending on your benefits, you may be charged more if you receive a brand drug when a generic is available. We may not ask you to pay the difference if there is a medical reason you need to take the brand name drug. There are some steps you must take:
    • Your provider should send in a document to the Food and Drug Administration to let them know you cannot take the generic and why. You can find more information and the form to submit at http://www.fda.gov/Safety/MedWatch
    • Your provider should review the attached criteria, and if you meet these guidelines, they can then submit information via this fax form or through CoverMyMeds.