Your plan for better healthSM1

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 (800) 672-7897 or fax a request form to (800) 795-9403.

Drugs Requiring Prior Approval Utilization Management Criteria Physician Fax Request Form
Growth Hormones All Growth Hormones Call (800) 672–7897 for prior approval
Insulin-like Growth Factors All Insulin-like Growth Factors Call (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 (800) 672-7897 for prior approval
Antipsoriatics
Respiratory
(Xolair®)		 Xolair® Use Xolair® Fax Request Form
Orencia®
Remicade®
Rituxan® (for Rheumatoid Arthritis ONLY)		 Orencia®
Remicade®
Rituxan® (for Rheumatoid Arthritis ONLY) 		Orencia®
Remicade®
Rituxan® (for Rheumatoid Arthritis ONLY)
Proton Pump Inhibitors
(effective 10/01/08)
  • Aciphex®
  • Nexium®
  • Omeprazole
  • Pantoprazole
  • Prevacid®
  • Zegerid®
  • Aciphex®
  • Nexium®
  • Omeprazole
  • Pantoprazole
  • Prevacid®
  • Zegerid®


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 (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 Triptan Fax Request Form

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.

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