Blue Cross and Blue Shield of North Carolina (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 (NDC) properly listed with the Food and Drug Administration (FDA).

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

Members may contact Customer Service at Blue Cross NC 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:

• To submit requests electronically (preferred method), please go to providerportal.surescripts.net/ProviderPortal/login, ⁠ MHK Provider Portal (accessed via Blue e), or CoverMyMeds Portal⁠ using Plan/PBM Name “BCBS NC”.
• Fax: Faxes can be sent to the fax number on the bottom of the fax form.
• By phone: Call the number for the member's plan. 
  • Blue Medicare HMO^℠ / PPO^℠: 888-296-9790 (TTY 711)
  • Blue Medicare Rx^℠ PDP: 888-298-7552 (TTY 711)
  • After normal business hours, messages can be left in the Medicare Part D After-Hours Exception mailbox at the plan's phone number.

The necessary information to process a request for drugs not covered on the formulary is outlined in the criteria below. All non-formulary exception requests that get approved will follow the tier 4 cost-share amount. Tier exception requests are not permissible on non-formulary exception approvals. Please be advised that incomplete forms may delay processing.

• Non-Formulary Exception Criteria (PDF)
• Non-Formulary Exception fax form (PDF)

The necessary information to process a request that a drug be covered at a lower cost share is outlined in the criteria below. Tier 5 drugs are not eligible for Tier Exception requests. Please be advised that incomplete forms may delay processing.

• Tier Exception Criteria (PDF)
• Tier Exception fax form (PDF)

Blue Cross NC only covers two brands of diabetes test strips for Medicare Advantage members: Lifescan (OneTouch) and Ascensia (Contour). All other test strips are not covered. Members can switch to covered diabetes test strips and receive a new compatible meter at no cost to them.

All diabetes test strips must be filled at a network retail or mail order pharmacy. Test strips can no longer be filled through durable medical equipment (DME) suppliers. 

Diabetes test strips have a designated quantity that will be covered. These limits are designed to align with blood sugar testing recommendations. If the provider feels it is medically necessary to exceed the set limit, they must request prior approval before the higher quantity can be covered.

Preferred Continuous Glucose Monitoring (CGM) products obtained through the pharmacy include Dexcom G6, Dexcom G7 when used with a Dexcom Receiver, Abbott Freestyle Libre, Freestyle Libre 2, and Freestyle Libre 3 when used with a Freestyle Libre receiver.

Blue Cross NC will consider coverage of other diabetes testing supplies and quantity limit exceptions. These requests should be submitted on the appropriate Diabetes Testing Supplies fax form. The necessary information to process a request for Diabetes Testing Supplies is outlined in the criteria.

• Test Strips and Meters Fax Form (PDF)
• Test Strips and Meters Prior Authorization Criteria (PDF)
• Continuous Glucose Monitor Fax Form (PDF)
• Continuous Glucose Monitor Prior Authorization Criteria (PDF)

There are some situations when certain drugs are covered under Medicare Part B. See the CMS Coverage database⁠ 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.

• Medicare Part B vs Part D fax form (PDF)

There are some drugs that require Step Therapy and / or Prior Authorization under Medicare Part B.

Part B Step Therapy is a program that requires members to first try a safe, effective, lower-cost drug to treat their condition before Blue Cross NC will cover another drug for that condition. Please see the Drug List below for those drugs requiring Step Therapy under Medicare Part B.

Part B Prior Authorization is a review of the medical drug prior to administration to determine if the drug is eligible for coverage by Blue Cross NC. Coverage determinations will be made in accordance with guidelines set forth by the Centers for Medicare & Medicaid Services (CMS), including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and medically accepted indications.

These requests should be submitted on the appropriate Medicare Part B Prior Authorization or Part B Step Therapy fax form. Drug-specific fax forms and criteria can be found on the Drug Search page.

• Medicare Part B Step Therapy and Prior Authorization Drug List

Learn how to get rid of expired, unwanted, or unused prescription drugs at home or through a drug take back site.

If you are affected by a change in which your drugs are removed from the formulary¹ (no longer covered), or in which your drugs are moved to a tier requiring a higher member cost share, Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx will mail you a notification. This notification will be sent at least 30 days before the formulary change will take effect. The plan will tell you why the change is being made and will list alternative drugs with the corresponding tier.

You are encouraged to use this 30-day time frame to have your drug switched to an appropriate alternative medication. You also have the option to ask Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx for a coverage exception.

Please note: Notification about drugs that are removed from the market due to safety reasons or due to the plan's determination that they are non-Part D drugs will not be sent within 30 days of removal from the market.

Switching to a 90-day supply of your prescriptions is an easy way to stay on track with your medications, especially if you have chronic health issues like diabetes, high blood pressure, or high cholesterol. It can help you stick to your treatment plan and cut down on trips to the pharmacy.

Choose the option that works best for you:

• Mail order: Get your medications delivered to your door for free with Amazon Pharmacy.
• Retail pharmacy: Check with your local pharmacy to see if they offer 90-day supplies of your medicine. This will vary by pharmacy.

Learn more about Amazon Pharmacy and getting your prescriptions by mail.