Prior Review and Quantity Limitations How Drug Benefits Work | Prescription Drug Search | Copay Tier | Prior Review and Limitations | Injectable Medications | Over-the-Counter Medications | Medication Safety | Preventive Rx
Prior ReviewSome medications require prior review from BCBSNC before the prescription can be accepted for payment. Blue CareSM, Blue OptionsSM, Blue ChoiceSM, and Blue AdvantageSMPrior review requires that your physician contact BCBSNC at 1-800-672-7897 or fax a request form to 1-800-795-9403.
Restricted-Access DrugsFor the non-preferred 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.
1Certification is not required for patients already taking a nonpreferred SSRI antidepressant (prescription claim within the past 12 months). Quantity LimitationsBCBSNC covers certain medications up to a set quantity. Quantity limitations are designed to help identify excessive use of drugs. If a physician feels it is medically necessary to exceed quantity limitations on your medication, he 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:
Benefit LimitsCertain 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.
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.
* 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. |
