Drug Information

For Medicare Members

Prior Approval and Quantity Limits

Some drugs require more than a provider's prescription in order to be covered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC) Blue Medicare plans.

This page provides details regarding the following; click on any link below to be taken to the specific section:

What You Need to Know:

You can access the member's formulary  for detailed information regarding covered drugs and drugs requiring review by Blue Cross NC.

Members may contact Customer Service at Blue Cross NC (Blue Medicare HMO 888-310-4110; Blue Medicare PPO 877-494-7647; Blue Medicare Rx 888-247-4142) in order to request a drug. All requests require a physician's supporting statement before the drug can be considered for payment. 

The member's prescribing provider may initiate a request with the plan in one of the following ways:

  • Electronic request (preferred): We have teamed with CoverMyMeds  to offer electronic review submissions.
  • Fax: Specific fax forms are listed below. Faxes can be sent to the fax number on the bottom of the form.
  • Telephone: Calling the plan (Blue Medicare HMO 888-310-4110; Blue Medicare PPO 888-296-9790; Blue Medicare Rx 888-298-7552). After normal business hours, messages can be left on the Medicare Part D After-Hours Exception voicemail.

Blue Cross NC is responsible to make sure all drugs covered under Part D are prescribed for medically-accepted indications, and that each prescription drug has a drug product national drug code properly listed with the Food and Drug Administration.

2018 Formulary Guides

The list of drugs covered on each plan, along with any restrictions for those drugs, can be found in the formulary guides below.

Prior Authorization and Step Therapy

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. Please see the member's formulary  for drugs that require review.

2018 Prior Authorization Criteria

Step Therapy is a program that requires members to first try one drug to treat their condition before Blue Cross NC will cover another drug for that condition. Please see the member's formulary  for drugs that require review.

2018 Step Therapy Criteria

Drug Search for Prior Authorization and Step Therapy

The easiest way to find the appropriate fax form and criteria for your member's plan is to use the search box below. The criteria and corresponding fax form will be displayed, along with details on which plans require the review.

Search by drug name:
Or click the first letter of your drug to view lists:
To find a drug, use the search above or select a letter from the list above.

Brand Drug Name: {{header}}

Prior Authorization Required On Prior Authorization Not Required
, Not Required
Quantity Limits Apply On Quantity Limits Do Not Apply
Step Therapy On Step Therapy Does Not Apply
, Does Not Apply
Formulary Exception On Formulary Exceptions Do Not Apply
, Does Not Apply
Fax Forms Fax Form

No results found for '{{header}}'

Quantity Limitations

Certain drugs have a designated quantity that will be covered. 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. For some of these drugs, if the provider feels it is medically necessary to exceed the set limit, he/she must request prior approval before the higher quantity can be covered. 2018 Quantity Limitations are listed in the Formulary Guides above. Requests can be submitted to Blue Cross NC using the Quantity Limit fax form below.

Non-Formulary Exceptions

The necessary information to process a request for drugs not covered on the formulary is outlined in the criteria below. Please be advised that incomplete forms may delay processing.

Tier Exceptions

The necessary information to process a request that a Tier 2 or Tier 4 drug be covered at the next lower copayment level is outlined in the criteria below. Please be advised that incomplete forms may delay processing.

Medicare Part B or Medicare Part D Drugs

There are some situations when certain drugs are covered under Medicare Part B. See the CMS Coverage database at https://www.cms.gov/medicare-coverage-database/  or DME-MAC Jurisdiction C at http://www.cgsmedicare.com/  for Medicare Part B drug coverage clarification.

If these drugs are not eligible for coverage under Medicare Part B, they may be covered under Medicare Part D with prior approval by the plan. These requests should be submitted on the Medicare Part B vs Part D fax form below.

Compounded Drugs

Compounded drugs require review for consideration of payment. As a whole, compounded drugs do not satisfy the definition of a Medicare Part D drug, as outlined in Chapter 6 of the Medicare Prescription Drug Manual (Section 10.4). Therefore, each individual ingredient of a compounded drug must be reviewed. Please note, bulk powders do not satisfy the definition of a Medicare Part D drug and are not covered by Medicare Part D. Requests for coverage of a compounded drug should be submitted on the Compounded Drugs fax form below.

Hospice requests

The form below contains the necessary information for requests of coverage for prescription drugs under Medicare Part D when the member is in Hospice care, and it is believed the drugs should not be covered under the Medicare Part A hospice benefit.

Drugs Excluded from Coverage

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

Refer to the Excluded Drugs list. Please keep in mind the attached list is updated quarterly and is not all inclusive. You can also refer to your Evidence of Coverage for more information.

1 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.

Using Medicare Prescription Drug Coverage

If your plan includes Medicare prescription drug coverage, learn how easy it is to fill your prescriptions at a local pharmacy or through mail order. In order to obtain the greatest savings on your prescription medications, please visit one of our preferred network providers.

Summary of Benefits

Evidence of Coverage

For more details about your plan, view the information below.

Blue Medicare Rx Frequently Asked Questions

Whom do I call if I have questions?

If you have questions regarding your Blue Medicare Rx, please call Customer Service at 1-888-247-4142. (TTY only, call 1-888-247-4145). We are available for phone calls 8.a.m. to 8 p.m. daily. Calls to these numbers are free. If you have questions in general about Medicare prescription drug coverage or about Medicare, you may call Medicare at 1-800-633-4227. TTY/TDD users may call Medicare at 1-877-486-2048.

What is Medicare prescription drug coverage?

As of January 1, 2006, Medicare began offering prescription drug coverage to help you pay for the prescription drugs you need. The coverage is designed to help you by covering prescription drugs at participating pharmacies close to where you live and through mail order.

Everyone with Medicare is eligible for this new coverage; however, the coverage is not mandatory. It is a voluntary program that you may choose to purchase annually.

Medicare prescription drug coverage is insurance. Private companies, like Blue Cross and Blue Shield of North Carolina provide the coverage.

How does the coverage work?

Medicare has designed a "standard benefit." Companies may offer additional enhanced plans, but they must offer a standard benefit package that is at least equal in value to Medicare's standard benefit as follows:

5% coinsurance - After your total out-of-pocket costs reach $5,000, you will pay very little for prescription drugs. You will pay only 5% (or $3.35 generic/$8.35 brand name, whichever is greater) for prescription drugs and your insurance company will pay the rest.
100% coinsurance - After your total drug costs reach $3,750, you will be responsible for all of your prescription drug costs until you reach an annual out-of-pocket limit of $5,000. This is referred to as the "coverage gap."
25% coinsurance - After the first $405, you will be responsible for 25% of the total cost of your prescription drugs. The Plan will pay 75% of your total drug costs until they reached a total of $3,750.
$405 deductible - You will be responsible for 100% of the first $405 in total prescription drug costs in each calendar year before your prescription drug benefit begins.

How will I know if my medications are on the Blue Cross NC formulary1?

  1. You can search for specific drugs online.

  2. You can call Customer Service at 1-888-247-4142. (TTY only, call 1-888-247-4145). We are available for phone calls 8.a.m. to 8 p.m. daily. Calls to these numbers are free.

What drugs are covered under Medicare prescription drug coverage?

Each plan provider will establish its own formulary, or list of prescription drugs, that it will cover. Although formularies must meet certain requirements set by Medicare, they still differ by plan.1

Medicare prescription drug coverage will include:

  • Prescription drugs
  • Vaccines
  • Insulin
  • Certain medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs and gauze).

Generally speaking, Medicare prescription drug coverage covers drugs that meet the following criteria:

  • They must be available only by prescription
  • They must be approved by the Food and Drug Administration
  • They must be used and sold in the United States
  • They must be used for a medically necessary prescription

Certain drugs, or classes of drugs, will not be covered because they are excluded by law, such as over the counter medicines like aspirin.

To learn which drugs are covered by Blue Cross NC Blue Medicare Rx (PDP) plans, search our list of covered drugs, formulary (list of covered drugs).1

Which pharmacies participate?

Click here to Find a Pharmacy.1

Are mail-order drugs available through Medicare prescription drug coverage?

You have the convenience of ordering your prescriptions from the mail order pharmacy. You can purchase up to a 90-day supply through mail order, and your medications will be delivered directly to your home. Depending on your plan, there may be savings available to you if you use the mail option.

Can I change plans when I want to?

Congress designed Medicare prescription drug coverage on an annual enrollment cycle. This means that each year, you will have the option to re-enroll in your existing Medicare prescription drug coverage plan or change plans between October 15 and December 7 each year.

You may also have another opportunity during the year to switch plans, under limited circumstances. For example, if you move out of your plan's service area, you'll have an opportunity to choose another plan that serves your new area.

Must I continue to pay my Medicare Part B premium?

Yes. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Whom do I call if I have questions regarding late enrollment penalty?

For questions regarding late enrollment, you may call Customer Service at 1-888-247-4142. (TTY only, call 1-888-247-4145). We are available for phone calls 8.a.m. to 8 p.m. daily. Calls to these numbers are free.

What if I have a limited income?

If you have Medicare and have limited income and resources, you may qualify for special financial assistance to help you pay for your Blue Medicare Rx costs. The amount of assistance you qualify for will depend on your income and resources:

In 2017, if your annual income is below 18,090 for a single person (or $24,360 if you are married and living with your spouse), you may qualify for financial assistance. Slightly higher income levels may apply if you provide half support to other family members living with you. If your resources (including your savings and stocks, but not counting your home or car) are under $13,820 (for a single person) or under $27,600 (for a married couple) you may qualify for financial assistance.2 Beneficiaries interested in qualifying for extra help with Blue Medicare Rx costs should call:

Medicare at 1-800-MEDICARE (1-800-633-4227)

TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week. Your state Medicaid office The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778. If you qualify for extra help with your Blue Medicare Rx, your premium and drug costs will be lower. When you join Blue Cross NC, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay.

1 Formulary and Pharmacy networks may change at any time. You will receive notice when necessary.

2 Medicare.gov October, 2015.

Low Income Subsidy and Best Available Evidence

Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get extra help.

2018 LIS Table

Your level of extra help Monthly Premium for Blue Medicare Rx (PDP)
Standard (S5540-002) * Enhanced (S5540-004) *
100% $47.30 $85.50
75% $54.90 $93.10
50% $62.40 $100.60
25% $70.00 $108.20

*This does not include any Medicare Part B premium you may have to pay.

Blue Medicare HMO's and Blue Medicare PPO's premium includes coverage for both medical services and prescription drug coverage.

If you aren't getting extra help, you can see if you qualify by calling:

  • Your State Medicaid Office, or
  • The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.


If you have any questions, please call Customer Services at 1-888-247-4142, (TTY only, call 1-888-247-4145). We are available for phone calls 8.a.m. to 8 p.m. daily. Calls to these numbers are free.

In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.

To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.

Please click on the link to CMS website below for materials related to the CMS Best Available Evidence (BAE) policy.

Help with Premiums for Eligible Individuals

Blue Cross and Blue Shield of NC partners with Altegra Health to help you get the benefits and extra help to which you may be entitled. Altegra Health through its MyAdvocateTM program assistance will discuss your personal situation and provide an assessment of the availability of assistance.


MyAdvocateTM will perform an individual screening to determine your eligibility for Medicaid services and government assistance with your MedAdvantage premium based on your income and financial asset level. If eligible, it will help you through the enrollment process.

Extra Help (Part D) Program

This program identifies qualifying seniors and the disabled who are eligible to receive extra help to pay for prescription medication and help to complete the program application.

Your Privacy is Important

In order to make the assessment, MyAdvocateTM will gather personal financial information necessary to make a determination, so be prepared for questions regarding your finances. Rest assured that Altegra does not share this information with any company or agency other than government agencies that require it should you qualify. The Blue Cross NC contract with Altegra Health requires that your information be protected. Blue Cross NC does not receive the information that Altegra gathers.

Source: http://altegrahealth.com/solutions/program-assistance/eligibility-enrollment-assistance/