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Pharmacy Benefits

Understanding non-formulary drugs

Understanding 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 resources.

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

  1. Log in to Blue Connect℠ or register for a new account.
  2. Click the Prescription tab (found at the top of the insurance plan info box near Health, and Dental, Vision, if you have them)
  3. Click Find a Drug to open the Prime Therapeutics website, then click Medicines and Find Medicines.
  4. Search for your prescription drug by typing a drug name in the blue search box.
  5. A list of drugs should appear. Choose the one you want (paying attention to dosage, quantity, etc.), then click Submit

No Blue Connect account? Try the Blue Cross NC 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, MHK Provider Portal (accessed using Blue e), or SureScripts.

The prescription must meet the Non-Formulary Exception Criteria (PDF) to receive approval. If your doctor submits all details online and the request is approved, you may be able to pick up your prescriptions at the pharmacy in less than 2 hours.

Your doctor can also send us requests by fax or mail:

  • Fax: 800-795-9403
  • Mail: 
    Blue Cross NC
    Attn: Corporate Pharmacy
    PO Box 2291, Durham, NC 27707

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.

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.

This benefit remains available 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.

For other members, 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*) (5mL)
  • 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) (16,800 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 that you get prior authorization before it is 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 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. Please refer to the list for specific weight loss drugs that are not covered (PDF).

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.