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Experience Health

Plan documents

Access information on your plan benefits, prescription drugs, eligible pharmacies, claims, and more.

Prescription drugs and pharmacy

Medicare Part D benefits exclude the following types of drugs or drug classes from coverage:

  • Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose such as morbid obesity)
  • Agents when used to promote fertility
  • Agents when used for cosmetic purposes or hair growth
  • Agents when used for the symptomatic relief of cough and colds
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Nonprescription drugs
  • Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
  • Agents when used for the treatment of sexual or erectile dysfunction

There are some drugs that require Step Therapy and/ or Prior Authorization under Medicare Part B.

Part B 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. Please see the Drug List below for those drugs requiring Step Therapy under Medicare Part B.

Part B Prior Authorization is a review of the medical drug prior to administration to determine if the drug is eligible for coverage by Blue Cross NC. Coverage determinations will be made in accordance with guidelines set forth by the Centers for Medicare & Medicaid Services (CMS), including National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), and medically accepted indications.

These requests should be submitted on the appropriate Medicare Part B Prior Authorization or Part B Step Therapy fax form. Drug-specific fax forms and criteria can be found in the Drug Search box under the Prior Authorization and Step Therapy section of this webpage.

Claims and enrollment

Programs, forms, and policies

Your member portal

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833-905-1311 (TTY: 711)


© 2024 Experience Health, Inc. All rights reserved.

For accommodation of persons with special needs at sales meetings, call 833-905-1311 (TTY: 711), 8 AM through 8 PM, 7 days a week.

Experience Health is an HMO plan with a Medicare contract. Enrollment in Experience Health Medicare Advantage (HMO) depends on contract renewal.

The federal government requires all Medicare Advantage members to continue paying their Part B premium each month.

To join Experience Health Medicare Advantage (HMO), you must have Medicare Part A and Part B, and live in the service area (Durham, Franklin, Granville, Lee, Orange, Person, Vance or Wake counties, North Carolina). Please contact the plan for more information. Medicare beneficiaries may also enroll in Experience Health Medicare Advantage (HMO) through the CMS Medicare Online Enrollment Center located at

This information is not a complete description of benefits. Call 833-905-1311 (TTY: 711) for more information. Other providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Experience Health Medicare Advantage (HMO) members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

ATTENTION: If you speak a non-English language, call 833-905-1311 (TTY: 711) and you will be connected to an interpreter who will assist you at no cost.

SilverSneakers® is a registered trademark of Tivity Health. © 2023 Tivity Health, Inc. All rights reserved. Tivity Health is an independent company providing fitness services on behalf of Experience Health.

Blue Cross NC contracts with independent companies to provide supplemental benefits. Those companies are responsible for the services they provide. They do not provide Blue Cross or Blue Shield products or services. Marks and trade names are property of their respective owners.

®, ℠ Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Experience Health is an independent licensee of the Blue Cross and Blue Shield Association, serving North Carolina.

This page was last updated 2024-03-01

H3777_EX5028_M_2024 CMS Accepted 02282024