Most patients with Blue Cross and Blue Shield of North Carolina (Blue Cross NC) health insurance also have a medication plan to cover the medications they get at their pharmacy. Each medication plan comes with a list (or formulary) that shows you what medications are covered.
Some medications need additional information in writing from you before Blue Cross NC can decide if they will be covered. Our drug search tool shows the restricted medications our members use most, the requirements for approval, and the details you must send us to get them approved.
Providers must explain in writing why patients need a certain medication before Blue Cross NC can decide if it will be covered.
To encourage the proper use of prescription medications, Blue Cross NC may restrict the amount of medicine an insurance plan covers. This may mean taking fewer pills each day without changing the total strength of the medication.
Blue Cross NC requires that patients first try a medication or device that is not restricted before a restricted medication will be approved. Patients may be covered for a restricted medication if providers tell Blue Cross NC in writing that:
A non-formulary medication is one that isn't on a patient's Blue Cross NC medication list. Not all medication lists or formularies have non-formulary medications. Providers must confirm that a patient has tried the medication(s) on their list first, and that they were ineffective or harmful. Also, any medication-specific clinical criteria must be met before approval (available in the Drug Search).
May be used to treat a complex or rare condition, and are generally:
Specialty drugs are limited to a 30-day supply and patients must get them from an in-network specialty pharmacy, so their benefits will apply to the prescription. In-network pharmacy options vary based on the patient's plan benefits.
For fastest processing, please submit requests online using CoverMyMeds. If all details are submitted online and the request is approved, the member may be able to pick up their prescriptions at the pharmacy in less than 2 hours.
Other processing methods include:
Once we have all required information, we'll make a decision within 3 business days and notify you. Requests are processed within 72 hours, unless urgent.
Urgent requests are handled within 24 hours. An urgent request is when you believe a delay would seriously jeopardize the life or health of the patient, the patient's ability to regain maximum function, or would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested.
Authorization for Essential Formulary Medications
Authorization for Net Results Formulary Medications
For members on the Net Results Medication List (formulary), if the request for a non-formulary medication is approved, these cost levels or "tiers" will apply:
Non-specialty medication = Tier 4
Specialty medication = Tier 5
Some medications may not be covered by the patient's plan or may have a limited amount the patient can receive. The following is a sample list of Drugs with Limited or No Coverage. Not all limited medications are listed.
For self-funded and ASO patients, you may need to call Blue Cross NC Customer Service for medication limits that may apply. If you are unsure if your patient's group is an underwritten or self-funded/ASO group, call the customer service number listed on the back of your patient's member ID card.
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, this benefit will remain available. Otherwise, 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:
*Requires prior authorization before being covered.
Underwritten and Individual / family plans:
Tadalafil (Cialis) 2.5mg or 5mg: 30 tablets per 30 days
4 tablets or units per 30 days
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:
Don't let your patient over pay. They could be charged more if you prescribe a brand-name medication instead of a generic. If there's a medical reason the patient needs a brand-name medication, please:
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
© 2023 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.