Medicare
Prescription drug coverage limitations and exclusions
Some drugs covered by Medicare may have additional requirements or limits on coverage.
Limits on prescription drug coverage
Prior authorization, step therapy, and quantity limits are types of restrictions on prescription drug coverage. You can find out if a drug requires further review in the member's plan formulary, available in the Medicare Forms Library, or by using the drug search.
Prior Authorization
Prior Authorization is a program that requires members to meet certain criteria prior to a drug being covered. It may be used to encourage the appropriate use of prescribed drugs based on the U.S. Food and Drug Administration (FDA) approved labeling and other medical literature.
- 2026 Prior Authorization Criteria Blue Medicare Rx Standard (PDP) (PDF)
- 2026 Prior Authorization Criteria Blue Medicare Rx Enhanced (PDP) (PDF)
- 2026 Prior Authorization Criteria Blue Medicare (PPO) Employer Group Complete, Blue Medicare Rx (PDP) Employer Group Complete, Blue Medicare (HMO) Employer Group Complete (PDF)
- 2026 Prior Authorization Criteria Blue Medicare (HMO) Employer Group MAPD, Blue Medicare (PPO) Employer Group MAPD (PDF)
- 2026 Prior Authorization Criteria Blue Medicare Rx (PDP) Employer Group HCE (PDF)
- 2026 Prior Authorization Criteria Blue Medicare Choice (HMO), Blue Medicare Enhanced (HMO-POS), Blue Medicare Essential (HMO), Blue Medicare Essential Plus (HMO-POS), Blue Medicare PPO Enhanced (PPO), Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)
Step therapy
Step Therapy is a program that requires members to first try a safe, effective, lower-cost drug to treat their condition before Blue Cross NC will cover another drug for that condition.
Quantity limits
Quantity limits are restrictions our plan puts on the amount of drug we will cover per prescription. These limits are designed to identify the excessive use of drugs which may be harmful in large quantities, to highlight the potential need for a different type of treatment, and to match dosing recommendations / requirements set by the manufacturer and the FDA.
Limitations
Our Medicare prescription drug coverage has rules to ensure the quality of members' care.
For Blue Medicare Advantage HMO℠, Blue Medicare Advantage℠ PPO, and Blue Medicare Rx℠ PDP:
- Certain drugs have quantity limits.
- Certain drugs require prior authorization.
- Certain drugs require step therapy.
- Compounded medications require an exception request to be approved.
- Drug benefits or services not described in the plan formulary or the Evidence of Coverage, or not required by law or regulations, are not covered.
- Drugs covered by Medicare Part B are not payable as Part D benefits. (Refer to your Medicare Part B coverage documents for Part B drug coverage.)
- If a Medicare beneficiary is eligible for Part D and does not sign up in the initial enrollment period, a Medicare late enrollment penalty may apply.
- Generally, coverage is not available to refill medications before 75% of the medication on-hand has been used. For example, if the prescription is written for a 30-day supply, you may refill once there is 7 or less days supply of the medication on-hand.
- Members must use network pharmacies to receive full benefits.
- Plan benefits and premium are subject to change annually.
- Prescriptions filled by pharmacies outside the United States or its territories, even for a medical emergency, are not covered.
- Prescriptions filled prior to effective date of coverage or after disenrollment date are not covered.
- Replacement of lost or stolen prescriptions are not covered.
- The plan's contract may be canceled by either the plan or the Centers for Medicare & Medicaid Services.
- All claims must be received within 3 years of the fill date. For example, if a drug is purchased on January 31, 2026, the claim must be received no later than January 31, 2029. Claims received after this time frame will not be eligible for coverage.
For Blue Medicare Advantage HMO and Blue Medicare Advantage PPO:
- An exception request for a Tier 5 (Specialty Tier) drug to be paid at the brand or generic cost-sharing level is not permissible under this plan.
- Members enrolled under this plan may not have drug coverage through both a Medicare Part D prescription drug plan (PDP) and a Medicare supplemental plan.
- To enroll in a Blue Medicare HMO or Blue Medicare PPO plan, you must reside within the CMS approved service area.
For Blue Medicare Rx PDP:
- An exception request for a Tier 5 (Specialty Tier) drug to be paid at the brand or generic cost-sharing level is not permissible under this plan.
- If you are already enrolled in a Medicare Supplement or Medicare Advantage plan that includes Part D drug coverage (MAPD), you should not enroll in a stand-alone Part D prescription drug plan (PDP).
- To enroll in Blue Medicare Rx you must reside within North Carolina.
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Search for drugs with coverage limitations
The easiest way to find the appropriate fax form and criteria for your plan is to use our search tool.
Excluded drugs
Our plans use a prescription drug formulary. Benefits are limited to the drugs on this formulary unless an exception is approved by the plan.
Medicare Part D benefits exclude the following types of drugs or drug classes from coverage:
- Non-prescription drugs (also called over-the-counter drugs)
- Drugs used to promote fertility
- Drugs used for the relief of cough or cold symptoms
- Drugs used for cosmetic purposes or to promote hair growth
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs used for the treatment of sexual or erectile dysfunction
- Drugs used for treatment of anorexia, weight loss, or weight gain
- Outpatient drugs for which the manufacturer requires associated tests or monitoring services be purchased only from the manufacturer as a condition of sale
You can find more information in your Evidence of Coverage in the Medicare Forms Library.