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Knowledge Center

Non-formulary drugs

Your doctor may suggest you take some non-formulary drugs, or those not on your approved list. Learn how to request coverage of non-formulary medications.

Medicare members

For Medicare formulary exception requests, review our Medicare prescription drug coverage details.

See Medicare Prescription Drug Coverage Details

What are non-formulary drugs?

A formulary is a list of prescription medications covered by your Blue Cross and Blue Shield of North Carolina (Blue Cross NC) health insurance plan. Drugs that are not included in your formulary are called non-formulary drugs.

A drug may not be included in the formulary if a generic version is available or if an alternative drug has been shown to be safer or more effective.

A doctor may prescribe a non-formulary drug when covered therapies haven't been effective for you. If you and your doctor have decided that a non-formulary drug is right for you, your doctor can request approval. Getting approval helps you lower your out-of-pocket costs.

How to find your approved drugs list

Log in to your Blue Connect℠ member portal. Click the Prescription tab, then use Find a Drug to see if your specific drug is covered.

You can also use our drug search tool to find this information.

How to request approval for non-formulary drugs

To request approval for a non-formulary drug, your doctor needs to send in some additional information to ensure the medication meets the exception criteria. In general, these exceptions make sure that you need the medication, that other covered medications are not adequate for your needs, or that the drug or dose requested is medically necessary.

For fastest processing, ask your doctor to submit non-formulary medication requests online through CoverMyMeds.com, MHK Provider Portal (accessed by logging in to Blue e), or SureScripts.

The prescription must meet the non-formulary exception criteria to receive approval. All the information your provider needs and any forms your provider must fill out and submit can be found on our Provider's Prior Authorization for Prescription Drugs page.

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

Prescription drugs with limited or no plan coverage

Your plan may not cover some medications, or it may limit the amount you can receive. The following is a sample list of drugs with limited or no coverage. This list does not include all limited medications.

If you have questions about medication coverage, call the customer service number listed on the back of your member ID card.

For self-funded and administrative services only (ASO) patients, you may need to call Blue Cross NC customer service to understand medication limits that may apply. If you're 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.

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: Limited to a maximum of seven 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. 

  • Adipex-P (phentermine)
  • Benzphetamine
  • Contrave (naltrexone / bupropion)
  • Evekeo (when used for weight loss)
  • Diethylpropion
  • Diethylpropion ER
  • Lomaira
  • Phendimetrazine
  • Phentermine
  • Qsymia (phentermine / topiramate)
  • Saxenda
  • Wegovy
  • Xenical
  • Zepbound

Some expensive claims require you to receive prior authorization, which means getting approval of coverage in advance. Single claims over $10,000 require prior authorization (excluding antivirals, anti-infectives, anticonvulsants, insulin, specialty medications and medications already subject to Prior Authorization or Step Therapy requirements).

When choosing prescription medications, work closely with your doctor and share your formulary. You can work together to determine whether medications in your formulary will work effectively for your condition. If your doctor still recommends non-formulary medications, have your doctor begin the request process.