Drug search

Find your plan’s drug list (formulary) by checking your Rx letter code. Look in the bottom right corner of your Member ID card for a code like “2A” or “D4.”

You can also find the code on your digital ID card in the member portal.

• Rx codes with an A or B are Enhanced
• Rx codes with a C are Essential C
• Rx codes with a D or F are Essential Q/QS
• Rx codes with an E are ASO Net Results C

Your formulary will only be listed in categories that apply to you and your plan.

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.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) must approve a prior review before your plan will help cover the cost of certain prescription medications.

Other names for prior review include:

• Prior approval
• Prior authorization
• Prospective review
• Certification
• Precertification

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.

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.

Blue Cross NC must approve a prior review before your plan will help cover the cost of certain prescription medications, medical procedures, or health care services.

The prior review process includes several steps:

• Your doctor will submit the prior authorization to Blue Cross NC.
• Blue Cross NC will review the prior authorization.
• Approved prior reviews are sent back to your doctor who will let you know if it is approved.
• Denied prior reviews are sent back to your doctor with a reason for denial and information about how to submit an appeal to the insurance company.
• You must get a prior review approved before the services, treatments, or prescription are provided.

In an emergency, prior review isn't required. However, Blue Cross NC should be notified of an urgent or emergency admission by the second business day after the admission.

To request approval for a non-formulary drug, your doctor needs to send in some additional information to ensure the medication meets the exception criteria. In general, these exceptions make sure that you need the medication, that other covered medications are not adequate for your needs, or that the drug or dose requested is medically necessary.

For fastest processing, ask your doctor to submit non-formulary medication requests online through the CoverMyMeds portal⁠, MHK Provider Portal (accessed by logging in to Blue e), or SureScripts⁠⁠.

The prescription must meet the non-formulary exception criteria to receive approval. All the information your provider needs and any forms your doctor must fill out and submit can be found on our Provider's Prior Authorization for Prescription Drugs page.

If your request for a non-formulary drug is approved, these cost levels, or "tiers," will apply:

• Essential Q formulary = Tier 5
• Essential QS formulary = Tier 4
• Essential C formulary = Tier 5

Bring your Blue Cross NC member ID card to your in-network pharmacy along with a prescription from your doctor. You can also ask your doctor to send the prescription straight to your pharmacy.

Your pharmacist will automatically send a claim to Blue Cross NC. Once the claim processes, Blue Cross NC may cover a portion of the total cost without any additional paperwork required. Depending on your coverage, you may only be responsible for paying a copay.