Medicare prescription drug coverage details

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 properly listed with the Food and Drug Administration.

You can access the member's formulary⁠⁠ 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 or covermymeds.com⁠ 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 and Blue Shield of North Carolina (Blue Cross NC) only covers two brands of diabetes test strips for Medicare Advantage Prescription Drug Plan members: Lifescan (OneTouch) and Ascensia (Contour). All other test strips are not covered. The member can switch to a covered diabetes test strip and receive a compatible new 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, he / she 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 below.

• 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 (PDF)

Members enrolled in Blue Medicare HMO℠, Blue Medicare PPO℠, Healthy Blue + Medicare℠, or Experience Health Medicare Advantage℠ (HMO) with Medicare prescription drug benefits or Blue Medicare Rx℠ may be eligible for the Medication Therapy Management Program (MTM), in accordance with CMS requirements. The MTM Program helps members understand their medications better.

Who's eligible for the MTM Program?

1. Individual members eligible for the MTM Program services must meet all 3 criteria below:

• Have at least 3 of the following chronic conditions:
  • Alzheimer's disease
  • Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
  • Chronic congestive heart failure (CHF)
  • Diabetes
  • Dyslipidemia
  • End-stage renal disease (ESRD)
  • Human immunodeficiency virus /acquired immunodeficiency syndrome (HIV / AIDS)
  • Hypertension
  • Mental health (including depression, schizophrenia, bipolar disorder, and chronic/disabling mental health conditions)
  • Respiratory disease (including asthma, chronic obstructive pulmonary disease (COPD), and chronic lung disorders)
• Take at least 8 or more prescription medications covered by Part D
  
• Expect to spend more than $1,623 in 2025 on prescription medicines covered by Medicare Part D

and / or

2. Have an active coverage limitation for an opioid or frequently abused medicine as a result of a Drug Management Program.

What services does the MTM Program provide?

The MTM Program services include the following interventions for members and prescribers:

• An annual comprehensive medication review (CMR) with a pharmacist to go over prescription and non-prescription medications that you take.
• Quarterly Targeted Medication Reviews which look for any safety or other issues which may need attention. The member’s prescriber may be contacted if any issues are found.

What is a CMR?

A Comprehensive Medication Review (CMR) is a person-to-person review of your medications with a pharmacist or nurse. The appointment usually takes about 30 minutes. During that time the pharmacist will:

• Review the medicines you take
• Create a personal medicine list
• Help you understand how your medicines work
• Tell you about side effects from your medicines
• Answer any questions or concerns you have

How do eligible members enroll?

• If you are eligible, you will be automatically enrolled in the program. Eligible members will receive a letter inviting them to schedule a medication review with a pharmacist.
• You may return the participation form in the mail or call a toll-free phone number (866-686-2223 or TTY users call 711) between 10 AM and 6 PM Eastern Time, Monday through Friday (except major holidays).
• Participation in the program is voluntary.

How do members opt out (decline) participation in the program?

Members may opt out from participating in the program.

This can be done by calling the telephone number listed in the notification letter (866-484-3953 or TTY users call 711) 24 hours a day, 7 days a week.

When prompted, enter your opt-out personal security PIN. You may refuse individual services without having to opt out from the whole program.

What are the program goals?

• Educate members regarding their medications
• Increase understanding about how to take medications as prescribed
• Identify and prevent medical complications related to medication therapy

For more information regarding the MTM Program and a sample of a Personal Medication list from a CMR, please click on the following:

• MTM Program⁠⁠ (from the sign in screen, select your plan type to continue)
• Sample Personal Medication List (PDF)
• Sample Personal Medication List (Spanish) (PDF)

Members should refer to their Evidence of Coverage for more details on the MTM Program. This program is not considered a benefit and is offered at no cost to eligible members.

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.