Getting your patients' prescriptions covered
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.
Are your patient's prescription medications covered?
- Look for the "Rx" on their member ID card. It means they have medication coverage.
- Look for a capital letter or a capital letter/number combination after the "Rx" on your patient's card. The letter will tell you which drug list, or formulary, your patient's plan uses. The number gives information about the pharmacies in your patient's network.
- Enhanced Drug List: A, B
- Essential Drug List: C, D
- Net Results Drug List: E
- Visit the Find Care page.
- Select 'Look Up a Drug or Doctor.'
- Then select 'Browse as a guest of a group plan.'
- Select 'Drug or pharmacy' option.
- On the 'Select your Rx letter code screen,' choose which letter code matches the drug you're searching for.
- After you select the letter code, your browser will automatically show the Prime Therapeutics website.
- On the Prime Therapeutics site, select a drug list from the 'Choose your drug list' dropdown.
- Then type the name of the medicine or condition and select the corresponding drug.
- On the same 'Add a medicine' dropdown, select the dosage and frequency.
- Review the results - including requirements and delivery options - for the selected drug.
Medications that need Prior Authorization
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.
Words you may see in the drug search
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:
- The patient has already used the non-restricted medication and it wasn't effective in treating the condition; or
- The provider thinks the non-restricted medication is likely to be harmful to the patient's health or not effective in treating their condition.
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:
- Prescribed with special dosing or administration
- Prescribed by a specialist
- Significantly more expensive than alternative therapies
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.
Requesting medications not on your patient's Approved Medication List (Formulary)
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:
- Online (Preferred - for providers only): CoverMyMeds.com Some drugs if approved can be ready at the pharmacy in less than 2 hours.
- Fax: 800-795-9403
- Mail: Blue Cross NC, Attn: Corporate Pharmacy, PO Box 2291, Durham, NC 27707
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
- Consider if there's another medication they could take.
- Check to see if the new medication is on the medication list. If it's there, you're all set!
- If you still need the non-formulary medication, send us a request to approve the non-formulary medication.
- For approval, the patient must meet the Non-Formulary Exception Criteria (PDF). If the medication is listed in the Drug Search, these requirements may also apply.
- You must send all the details, with your signature, to Blue Cross NC.
- All requests can be submitted using CoverMyMeds or fax.
- If a medication is not listed in the Drug Search, request it using the Non-Formulary Exception Request Fax Form (PDF).
- If the medication is listed in the Drug Search, use the fax form shown there.
- If your request for a non-formulary drug is approved, these cost levels or "tiers" will apply: Essential formulary = Tier 5.
- For questions, or to check the status of your review, call us at 800-672-7897.
Authorization for Net Results Formulary Medications
- Consider if there's another medication the patient could take.
- If you still need to prescribe the drug requiring an MN-PA, send us a request for approval
- For approval, the patient must meet their plan's Medical Necessity Authorization Criteria (PDF). If the drug is listed in the Drug Search, these requirements may still apply.
- As the doctor or provider, you must send all your details, and your signature on the Medical Necessity PA Request Fax Form (PDF), to Blue Cross NC
- For questions or to check the status of your review, call us at 800-672-7897
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
Medications with limited or no plan coverage
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:
- 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) (1,500 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 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 for all other products
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:
- DermacinRx Pretrate
Brand-name drugs vs. generics
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.
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