Prior Approval and Quantity Limitations

Prior Approval

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

Blue Care^SM, Blue Options^SM, Blue Choice^SM, and Blue Advantage^SM

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	Enbrel® KineretTM Humira® Cimzia® Simponi®	Enbrel® KineretTM Humira® Cimzia® Simponi® effective 10/1/09
All Botulinum Toxins	FDA approved conditions	Call 1-800-672-7897 for prior approval
Antipsoriatics	Amevive® Enbrel® Humira®	Amevive® Enbrel® Humira®
Respiratory (Xolair®)	Xolair®	Use Xolair® Fax Request Form
Orencia® Remicade® Rituxan® (for Rheumatoid Arthritis ONLY)	Orencia® Remicade® Rituxan® (Prior Approval required for Rheumatoid Arthritis ONLY)	Orencia® Remicade® Rituxan® (Prior Approval required 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	Prior review for immune globulins effective 1/1/2010
Transmucosal Fentanyl	Transmucosal Fentanyl	Use Transmucosal Fentanyl Fax Request Form
Proton Pump Inhibitors (PPIs)* (updated 2/16/09)	Aciphex® Kapidex™ Lansoprazole Powder (for pharmacy compounding only; doesn't include Prevacid brand products) Prevacid® Prilosec® for oral suspension Protonix® 40mg Suspension Zegerid®	Use PPI Fax Request Form Requests DO NOT need to be submitted for the preferred PPIs omeprazole, pantoprazole, or Nexium-®
Intranasal Steroids* (effective 10/1/09)	Beconase AQ® Nasacort AQ® Omnaris® Rhinocort Aqua® Veramyst®	Use Intranasal Steroids Fax 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 Oral Bisphosphonates Fax Request Form Requests DO NOT need to be submitted for the preferred bisphosphonates alendronate, Fosamax Plus D, or Boniva.

*The nonpreferred PPIs, intranasal steroids and oral bisphosphonates listed will be considered restricted access drugs that require an initial physician certification prior to being covered.

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	Amerge® Axert® Frova® Imitrex® / sumatriptan Maxalt® Relpax® Zomig® Treximet®	Use Triptan Fax Request Form Quantity limit requests need only be submitted for members to get MORE than the allowable amounts listed.
Transmucosal Fentanyl	Actiq/fentanyl lozenges and Fentora®	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.