Requesting Medications Not on Your Patient's Approved Medication List (Formulary)įor fastest processing, please submit requests online using CoverMyMeds TM. In-network pharmacy options vary based on the patient's plan benefits.įor Patients with an Essential Medication List (Formulary): If your patient meets the Criteria for Approval of Restricted Products (pdf), and their list says that Prior Review (Prior Authorization) or Step Therapy is required for a medication, but the medication isn't in the Drug Search, please send a request to Blue Cross NC using this General Authorization Fax Form (pdf). 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. Significantly more expensive than alternative therapies.Prescribed with special dosing or administration.May be used to treat a complex or rare condition, and are generally: Also, any medication-specific clinical criteria must be met before approval (available in the Drug Search). Providers must confirm that a patient has tried the medication(s) on their list first, and that they were ineffective or harmful. Not all medication lists or formularies have non-formulary medications. Non-formularyĪ non-formulary medication is one that isn't on a patient's Blue Cross NC medication list. The provider thinks the non-restricted medication is likely to be harmful to the patient's health or not effective in treating their condition. The patient has already used the non-restricted medication and it wasn't effective in treating the condition or Patients may be covered for a restricted medication if providers tell Blue Cross NC in writing that:
Step Therapyīlue Cross NC requires that patients first try a medication or device that is not restricted before a restricted medication will be approved. This may mean taking fewer pills each day without changing the total strength of the medication. To encourage the proper use of prescription medications, Blue Cross NC may restrict the amount of medicine an insurance plan covers. Providers must explain in writing why patients need a certain medication before Blue Cross NC can decide if it 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. Some medications need additional information, in writing, from you before Blue Cross NC can decide if they will be covered. Medications that Need Prior Authorization
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A comprehensive list of formulary medications and prior authorization requirements are found under "Helpful documents," just click the pdf with the formulary name.
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How to Find Your Patient's Approved Medication List or Formulary Non-Discrimination Policy and Accessibility Services.
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