Prescription drugs

Providers must explain in writing why patients need a certain medication before Blue Cross NC can decide if it will be covered.

To encourage the proper use of prescription medications, Blue Cross NC may restrict the amount of medicine an insurance plan covers. This may mean taking fewer pills each day without changing the total strength of the medication.

Blue Cross NC requires that patients first try a medication or device that is not restricted before a restricted medication will be approved. Patients may be covered for a restricted medication if providers tell Blue Cross NC in writing that:

• The patient has already used the non-restricted medication and it wasn't effective in treating the condition; or
• The provider thinks the non-restricted medication is likely to be harmful to the patient's health or not effective in treating their condition.

A non-formulary medication is one that isn't on a patient's Blue Cross NC medication list. Not all medication lists or formularies have non-formulary medications. Providers must confirm that a patient has tried the medication(s) on their list first, and that they were ineffective or harmful. Also, any medication-specific clinical criteria must be met before approval (available in the Drug Search).

May be used to treat a complex or rare condition, and are generally:

• Prescribed with special dosing or administration
• Prescribed by a specialist
• Significantly more expensive than alternative therapies

Specialty drugs are limited to a 30-day supply and patients must get them from an in-network specialty pharmacy, so their benefits will apply to the prescription. In-network pharmacy options vary based on the patient's plan benefits.

Authorization for Essential Formulary Medications

• Consider if there's another medication they could take.
• Check to see if the new medication is on the medication list. If it's there, you're all set!
• If you still need the non-formulary medication, send us a request to approve the non-formulary medication.
• For approval, the patient must meet the Non-Formulary Exception Criteria (PDF). If the medication is listed in the Drug Search, these requirements may also apply.
• You must send all the details, with your signature, to Blue Cross NC.
  • All requests can be submitted using CoverMyMeds or fax.
  • If a medication is not listed in the Drug Search, request it using the Non-Formulary Exception Request Fax Form (PDF).
  • If the medication is listed in the Drug Search, use the fax form shown there.
• If your request for a non-formulary drug is approved, these cost levels or "tiers" will apply: Essential formulary = Tier 5.
• For questions, or to check the status of your review, call us at 800-672-7897.

Authorization for Net Results Formulary Medications

• Consider if there's another medication the patient could take.
• If you still need to prescribe the drug requiring an MN-PA, send us a request for approval
• For approval, the patient must meet their plan's Medical Necessity Authorization Criteria (PDF). If the drug is listed in the Drug Search, these requirements may still apply.
• As the doctor or provider, you must send all your details, and your signature on the Medical Necessity PA Request Fax Form (PDF), to Blue Cross NC
• For questions or to check the status of your review, call us at 800-672-7897

For members on the Net Results Medication List (formulary), if the request for a non-formulary medication is approved, these cost levels or "tiers" will apply:

Non-specialty medication = Tier 4
Specialty medication = Tier 5

For groups that in 2013 had a $5,000 lifetime maximum 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., Follistim AQ, Gonal-F*) (5mL)
• Oral ovulation stimulants (Clomid) (360 tablets)
• Subcutaneous injectable ovulation stimulants (e.g., Ovidrel*) (1,000 micrograms)
• Intramuscular injectable ovulation stimulants (e.g., Novarel, Pregnyl) (40,000 units)
• Menotropins (e.g., Menopur) (1,500 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., Prometrium* suppositories, Endometrin suppositories) (90 units)

*Requires prior authorization before being covered.

Underwritten and individual / family plans:

Tadalafil (Cialis) 2.5mg or 5mg: 30 tablets per 30 days
4 tablets or units per 30 days for all other products

All:

Not covered.

Limited to members that are planning pregnancy, currently pregnant, or breastfeeding.

In addition to the above benefit limitation, some prenatal vitamins are excluded from coverage entirely. These include, but are not limited to:

• Azeschew
• Azesco
• DermacinRx Pretrate
• Pregenna
• Prenara
• Prenatryl
• Prenatrix
• Trinaz
• Zalvit
• Ziphex

All: Not covered. Please see the Non-FDA Approved Medication and Product List (PDF) for specific medications that aren't covered.

All: Limited to maximum of 7 days for initial fill. If this is not the first fill, but Blue Cross NC does not have the patient's claims history, use this IR Opioid QL Criteria (PDF) and IR Opioid QL Fax Form (PDF).

Please see member guide for coverage.

Not covered as a standard benefit. Please see list for Specific OTC Drugs That Are Not Covered (PDF).

Please see member guide for coverage.

Not covered as a standard benefit. Please see list for Specific Weight Loss Drugs That Are Not Covered (PDF).

Single claims over $10,000 require prior authorization (excluding antivirals, anti-infectives, anti-convulsants, insulin, specialty medications, and medications already subject to Prior Authorization or Step Therapy requirements).

• Criteria Information (PDF)
• Fax Submission Information (PDF)