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.