Effective October 3, 2022, Blue Cross and Blue Shield of North Carolina’s (Blue Cross NC) Medicare Advantage plan is expanding Medicare Part B Step Therapy and Prior Authorization requirements for medications under Part B.
Listed below are links to our medical websites where providers can find the newest drug list, criteria and more information about the programs.
Prior Authorization will address medical necessity, while Step Therapy focuses on the use of safe, lower-cost alternatives. Please note, Step Therapy program requirements will only apply to patients new to these medications; current users will not be impacted.
|Blue Medicare - Prior Plan Approval | Prior Review | Blue Cross Blue Shield of North Carolina||https://medicare.bluecrossnc.com/medicare/prescription-drug-coverage|
|Blue Medicare Medical Guidelines - Alphabetical Index||https://www.bluecrossnc.com/providers/blue-medicare-providers/blue-medicare-medical-guidelines-alphabetical-index|
Please review these new requirements for Medicare Part B. On or after October 3, 2022, you will need to provide additional information to Blue Cross NC. For faster service, submit requests to Blue Cross NC electronically via CoverMyMeds™, our free online prior authorization tool.
Please be aware, that if prior plan approval of these medications is not given by Blue Cross NC Medicare Advantage, the service(s) may not be covered under the member’s Medicare Advantage plan, and the provider may be responsible for the entire cost of the drug and associated service(s). Providers cannot bill members for services when prior plan approval is required but the provider failed to obtain the request prior to rendering services. Additionally, if the member changes Blue Cross NC Medicare Advantage policies, you may need to certify they have met our medical necessity criteria under the new policy for the medication(s) in question.
Please refer to Medicare Providers “Prior Plan Approval” for the latest updates about our utilization programs. You can also find specific criteria and fax forms on the provider web portal or via CoverMyMeds™.
If you have questions, please call our Provider Blue Medicare line at 1-888-296-9790 for assistance.