Most people with Blue Cross and Blue Shield of North Carolina (Blue Cross NC) health insurance also have a drug plan to cover the drugs they get at their pharmacy. Each drug plan comes with a list (also known as a formulary) that shows you what drugs are covered.
The drug name, description and cost info will appear under "Selected medicines." If you need prior authorization or have other special requirements, that may be listed here also.
What is Prior Authorization? This means your doctor must explain in writing why you need a certain medication before Blue Cross NC can decide if it will be covered.
Our drug search tool shows the restricted drugs our members use most, and the details your doctor or provider must send us to get them approved.
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:
A non-formulary medication is one that isn't on a patient's Blue Cross NC medication list. Not all medication lists or formularies have non-formulary medications. Providers must confirm that a patient has tried the medication(s) on their list first, and that they were ineffective or harmful. Also, any medication-specific clinical criteria must be met before approval (available in the Drug Search).
May be used to treat a complex or rare condition, and are generally:
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.
For fastest processing, please submit requests online using CoverMyMeds. If all details are submitted online and the request is approved, you may be able to pick up your prescriptions at the pharmacy in less than 2 hours.
Other processing methods include:
Once we have all required information, we'll make a decision within 3 business days. Requests are processed within 72 hours, unless urgent. Urgent requests are handled within 24 hours.
Authorization for Essential Formulary Medications
Authorization for Net Results Formulary Medications
For members on the Net Results Medication List (formulary), if the request for a non-formulary medication is approved, these cost levels or "tiers" will apply:
Non-specialty medication = Tier 4
Specialty medication = Tier 5
Some medications may not be covered by your plan or may have a limited amount you can receive. The following is a sample list of drugs with limited or no coverage. Not all limited medications are listed.
For self-funded and ASO patients, you may need to call Blue Cross NC customer service for medication limits that may apply. If you are unsure if your group is an underwritten or self-funded / ASO group, call the customer service number listed on the back of your member ID card.
For groups that in 2013 had a $5,000 lifetime maximum and were able to carry this over due to updates to the Affordable Care Act, this benefit will remain available. Otherwise, the benefit is as follows (call customer service to confirm):
Underwritten and individual / family plans
Infertility drugs are limited to the following lifetime maximum per member:
*Requires prior authorization before being covered.
Underwritten and Individual / family plans:
Tadalafil (Cialis) 2.5mg or 5mg: 30 tablets per 30 days
4 tablets or units per 30 days
Not covered.
Limited to members that are planning pregnancy, currently pregnant, or breastfeeding.
In addition to the above benefit limitation, some prenatal vitamins are excluded from coverage entirely. These include, but are not limited to:
All: Not covered. Please see the non-FDA approved medication and product list (PDF) for specific medications that aren't covered.
All: Limited to maximum of 7 days for initial fill. If this is not the first fill, but Blue Cross NC does not have the patient's claims history, use this IR Opioid QL Criteria (PDF) and IR Opioid QL Fax Form (PDF).
Please see member guide for coverage.
Not covered as a standard benefit. Please see list for specific OTC drugs that are not covered (PDF).
Please see member guide for coverage.
Not covered as a standard benefit. Please see list for specific weight loss drugs that are not covered (PDF).
Single claims over $10,000 require prior authorization (excluding antivirals, anti-infectives, anti-convulsants, insulin, specialty medications, and medications already subject to Prior Authorization or Step Therapy requirements).
Don't over pay for medications. You could be charged more if you take a brand-name medication instead of a generic. If there's a medical reason you need a brand-name medication, please:
Medications are assigned to one of four, five or six categories known as copayment or coinsurance tiers, based on drug usage, cost and clinical effectiveness. Our prescription drug search can show you which tier applies to a specific medication based on your benefits plan.
Tier 1: lowest cost tier of prescriptions drugs, most are generic.
Tier 2: medium-cost, most are generic, and some brand-name prescription drugs.
Tier 3: higher-cost, most are brand-name, and some are specialty drugs.
Tier 4: highest-cost, most are specialty drugs.
Tier 1: lowest cost tier, most are generic.
Tier 2: medium-cost, most are generic, and some brand name.
Tier 3: high-cost, most are brand-name.
Tier 4: higher-cost, most are brand-name, and some specialty drugs.
Tier 5: highest-cost, most are specialty drugs.
Tier 1: lowest cost tier of prescription drugs, most are generic.
Tier 2: medium-cost, most are generic, and some brand name.
Tier 3: high-cost, most are brand-name.
Tier 4: higher-cost, most are brand-name, and some specialty drugs.
Tier 5: some of the highest-cost prescription drugs, most are specialty drugs.
Tier 6: highest-cost, most are specialty drugs.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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