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Drug search


Getting your prescriptions covered

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.

How to find your approved drugs list

  1. Log in to Blue Connect℠ or register for an account.
  2. Go to the Prescriptions page: Click Find a Drug, then Search for Prescription Drugs - Prime Therapeutics.
  3. Search for your prescription drug.
  4. Type a drug name in the blue search box and Submit. 

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.

Drugs that need prior authorization

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 find a drug, use the search above or select a letter from the list above.

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  • Specialty:
  • Prior Review Required On: ,
  • Value Prior Authorization: ,
  • Quantity Limits Required On: ,
  • Quantity Limits:
  • Restricted Access/Step Therapy:
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  • Formulary Exceptions:
  • Formulary Exceptions: ,
  • Nonformulary:
  • Nonformulary On: ,
  • Criteria: ,
  • Fax Form: ,
  • Note:

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Words you may see in the drug search

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.

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:

  • 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.

Requesting medications not on your approved medication list (formulary)

For fastest processing, please submit requests online using the Blue e Portal. 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:

  • Online (preferred - for providers only): Blue e Portal. Some drugs if approved can be ready at the pharmacy in less than 2 hours.
  • Fax: 800-795-9403
  • Mail: Blue Cross NC, Attn: Corporate Pharmacy, PO Box 2291, Durham, NC 27707

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

  • Consider if there's another medication that could be taken.
  • Check to see if the new medication is on the medication list. If it's there, you're all set!
  • If you still need the non-formulary medication, send us a request to approve the non-formulary medication.
  • For approval, you must meet the Non-Formulary Exception Criteria (PDF). If the medication is listed in the Drug Search, these requirements may also apply.
  • Your provider must send all the details, with their signature, to Blue Cross NC:
    • All requests can be submitted using CoverMyMeds or fax.
    • If a medication is not listed in the Drug Search, request it using the Non-Formulary Exception Request Fax Form (PDF).
    • If the medication is listed in the Drug Search, use the fax form shown there.
  • 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
  • For questions, or to check the status of your review, call us at 800-672-7897.

Authorization for Net Results Formulary Medications

  • Consider if there's another medication that could be taken.
  • If you still need the drug requiring an VPA, your provider should send us a request for approval
  • For approval, you must meet your plan's Value PA Criteria (PDF). If the drug is listed in the Drug Search, these requirements may still apply.
  • The doctor or provider must send all your details, and their signature on the Value PA Request Fax Form (PDF), to Blue Cross NC
  • For questions or to check the status of your review, call us at 800-672-7897

For members on the Net Results Medication List (formulary), if the request for a medication that requires Value Prior Authorization is approved, these cost levels or "tiers" will apply:

Non-specialty medication = Tier 4
Specialty medication = Tier 5

Medications with limited or no plan coverage

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:

  • Follitropins (e.g., Follistim AQ, Gonal-F*) (10mL)
  • Oral ovulation stimulants (Clomid) (360 tablets)
  • Subcutaneous injectable ovulation stimulants (e.g., Ovidrel*) (1,000 micrograms)
  • Intramuscular injectable ovulation stimulants (e.g., Novarel, Pregnyl) (40,000 units)
  • Menotropins (e.g., Menopur) (1,500 units)
  • Gonadotropin-releasing hormone antagonists (e.g., Cetrotide, Ganirelix) (3mg)
  • Progestins (e.g., Crinone 8%* gel) (101.25g or 90 syringes/applicators)
  • Progestins (e.g., Prometrium* suppositories, Endometrin suppositories) (90 units)

*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:

  • Azeschew
  • Azesco
  • DermacinRx Pretrate
  • Pregenna
  • Prenara
  • Prenatryl
  • Prenatrix
  • Trinaz
  • Zalvit
  • Ziphex

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).

Brand-name drugs vs. generics

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:

  1. Check the Request for Waiver of Brand Drug Fees (PDF) to see if you meet our requirements.
  2. Send a Safety MedWatch Form to the FDA to tell us why you can't take the generic.
  3. Send us a Request for Waiver Faxback Form (PDF) with your details.

Copayment drug tiers

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.

4-tier formulary

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.

5-tier formulary

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.

Medical Benefit: Site of Care / Place of Service for Medical Infusions Policy

How do members get prescriptions filled by mail?

The Blue Cross NC mail order prescription program offers you the convenience of receiving up to a 90-day supply of medication delivered to you with free standard day shipping through Amazon Pharmacy (MedsYourWay®) and Express Scripts Pharmacy (ESI). You can order your prescriptions online or through the mail – choose whatever works best for you.

For MedsYourWay, Amazon Prime members get free 2-day delivery; 5-day delivery without Amazon Prime. Follow the easy sign-up process at Amazon or call 855-963-4546. If you are not already an Amazon customer then you’ll need to sign up, confirm your identity and then follow the instructions.

For ESI, register online at Express Scripts or call 833-599-0450.