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Prescription drugs and pharmacy

Prior Authorization is a program that requires members to meet certain criteria prior to a drug being covered. It may be used to encourage the appropriate use of prescribed drugs based on the US Food and Drug Administration (FDA) approved labeling and other medical literature.

2024 Prior Authorization Criteria (PDF)

2025 Prior Authorization Criteria (PDF)

Members enrolled in Blue Medicare HMO℠, Blue Medicare PPO℠, Healthy Blue + Medicare℠, or Experience Health Medicare Advantage℠ (HMO) with Medicare prescription drug benefits or Blue Medicare Rx℠ may be eligible for the Medication Therapy Management Program (MTM), in accordance with CMS requirements. The MTM Program helps members understand their medications better.

Who's eligible for the MTM Program?

1. Individual members eligible for the MTM Program services must meet all 3 criteria below:

  • Have at least 3 of the following chronic conditions:
    • Alzheimer's disease
    • Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
    • Chronic congestive heart failure (CHF)
    • Diabetes
    • Dyslipidemia
    • End-stage renal disease (ESRD)
    • Human immunodeficiency virus / acquired immunodeficiency syndrome (HIV / AIDS)
    • Hypertension
    • Mental health (including depression, schizophrenia, bipolar disorder, and chronic / disabling mental health conditions)
    • Respiratory disease (including asthma, chronic obstructive pulmonary disease (COPD), and chronic lung disorders)
  • Take at least 8 or more prescription medications covered by Part D
  • Expect to spend more than $1,623 in 2025 on prescription medicines covered by Medicare Part D

and / or

2. Have an active coverage limitation for an opioid or frequently abused medicine as a result of a Drug Management Program.

What services does the MTM Program provide?

The MTM Program services include the following interventions for members and prescribers:

  • An annual comprehensive medication review (CMR) with a pharmacist to go over prescription and non-prescription medications that you take.
  • Quarterly Targeted Medication Reviews which look for any safety or other issues which may need attention. The member’s prescriber may be contacted if any issues are found.
What is a CMR?

A Comprehensive Medication Review (CMR) is a person-to-person review of your medications with a pharmacist or nurse. The appointment usually takes about 30 minutes. During that time the pharmacist will:

  • Review the medicines you take
  • Create a personal medicine list
  • Help you understand how your medicines work
  • Tell you about side effects from your medicines
  • Answer any questions or concerns you have
How do eligible members enroll?
  • If you are eligible, you will be automatically enrolled in the program. Eligible members will receive a letter inviting them to schedule a medication review with a pharmacist.
  • You may return the participation form in the mail or call a toll-free phone number (866-686-2223 or TTY users call 711) between 10 AM and 6 PM Eastern Time, Monday through Friday (except major holidays).
  • Participation in the program is voluntary.
How do members opt out (decline) participation in the program?

Members may opt out from participating in the program.

This can be done by calling the telephone number listed in the notification letter (866-484-3953 or TTY users call 711) 24 hours a day, 7 days a week.

When prompted, enter your opt-out personal security PIN. You may refuse individual services without having to opt out from the whole program.

What are the program goals?
  • Educate members regarding their medications
  • Increase understanding about how to take medications as prescribed
  • Identify and prevent medical complications related to medication therapy

For more information regarding the MTM Program and a sample of a Personal Medication list from a CMR, please click on the following:

Members should refer to their Evidence of Coverage for more details on the MTM Program. This program is not considered a benefit and is offered at no cost to eligible members.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) only covers two brands of diabetes test strips for Medicare Advantage Prescription Drug Plan members: Lifescan (OneTouch) and Ascensia (Contour). All other test strips are not covered. The member can switch to a covered diabetes test strip and receive a compatible new meter at no cost to them.

All diabetes test strips must be filled at a network retail or mail order pharmacy. Test strips can no longer be filled through durable medical equipment (DME) suppliers. 

Diabetes test strips have a designated quantity that will be covered. These limits are designed to align with blood sugar testing recommendations. If the provider feels it is medically necessary to exceed the set limit, he / she must request prior approval before the higher quantity can be covered.

Preferred Continuous Glucose Monitoring (CGM) products obtained through the pharmacy include Dexcom G6, Dexcom G7 when used with a Dexcom Receiver, Abbott Freestyle Libre, Freestyle Libre 2, and Freestyle Libre 3 when used with a Freestyle Libre receiver.

Blue Cross NC will consider coverage of other diabetes testing supplies and quantity limit exceptions. These requests should be submitted on the appropriate Diabetes Testing Supplies fax form. The necessary information to process a request for Diabetes Testing Supplies is outlined in the criteria below.

Medicare Part D benefits exclude the following types of drugs or drug classes from coverage:

  • Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose such as morbid obesity)
  • Agents when used to promote fertility
  • Agents when used for cosmetic purposes or hair growth
  • Agents when used for the symptomatic relief of cough and colds
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Nonprescription drugs
  • Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
  • Agents when used for the treatment of sexual or erectile dysfunction

There are some situations when certain drugs are covered under Medicare Part B. See the CMS Coverage database⁠⁠ for Medicare Part B drug coverage clarification.

If these drugs are not eligible for coverage under Medicare Part B, they may be covered under Medicare Part D with prior approval by the plan. These requests should be submitted on the Medicare Part B vs Part D fax form below.

There are some drugs that require Step Therapy and / or Prior Authorization under Medicare Part B.

Part B Step Therapy is a program that requires members to first try a safe, effective, lower-cost drug to treat their condition before Blue Cross NC will cover another drug for that condition. Please see the Drug List below for those drugs requiring Step Therapy under Medicare Part B.

Part B Prior Authorization is a review of the medical drug prior to administration to determine if the drug is eligible for coverage by Blue Cross NC. Coverage determinations will be made in accordance with guidelines set forth by the Centers for Medicare & Medicaid Services (CMS), including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and medically accepted indications.

These requests should be submitted on the appropriate Medicare Part B Prior Authorization or Part B Step Therapy fax form. Drug-specific fax forms and criteria can be found on the Drug Search webpage.

The necessary information to process a request for drugs not covered on the formulary is outlined in the criteria below. All non-formulary exception requests that get approved will follow the Tier 4 cost-share amount. Tier exception requests are not permissible on non-formulary exception approvals. Please be advised that incomplete forms may delay processing.

Quantity limits are restrictions our plan puts on the amount of drug we will cover per prescription. These limits are designed to identify the excessive use of drugs which may be harmful in large quantities, to highlight the potential need for a different type of treatment, and to match dosing recommendations / requirements set by the manufacturer and the FDA. 

The necessary information to process a request that a drug be covered at a lower cost share is outlined in the criteria below. Tier 5 drugs are not eligible for Tier Exception requests. Please be advised that incomplete forms may delay processing.

Our plan keeps track of the costs of your prescription drugs and the payments you have made. This way, we can tell you when you have moved from one coverage stage to the next. We share that information each month in your Part D Explanation of Benefits (EOB).

The EOB includes information for that month, totals for the year since January 1, drug price information, and lower-cost prescription options.

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Disclosures:

Blue Cross and Blue Shield of North Carolina is an HMO plan with a Medicare contract. Enrollment in Experience Health Medicare Advantage (HMO) depends on contract renewal.

To join Experience Health Medicare Advantage (HMO), you must have Medicare Part A and Part B, and live in the service area (Durham, Franklin, Granville, Lee, Orange, Person, Vance or Wake counties, North Carolina). Please contact the plan for more information. Medicare beneficiaries may also enroll in Experience Health Medicare Advantage (HMO) through the CMS Medicare Online Enrollment Center located at www.medicare.gov.

This information is not a complete description of benefits. Call 833-905-1311 (TTY: 711) for more information. Other providers are available in our network. 

The federal government requires all Medicare Advantage members to continue paying their Part B premium each month.

Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, sexual orientation or source of payment. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.

Links marked with an external site icon indicate that you're leaving BlueCrossNC.com and Blue Cross and Blue Shield of North Carolina's plan information. The site you're going to is either a third-party vendor contracted with Blue Cross NC to provide services or an external website independent of Blue Cross NC.

To view PDF documents, you need to download and install Adobe Acrobat Reader on your computer.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) offers several decision-support tools to aid you in making decisions around your health care experience. These tools are offered for your convenience and should be used only as reference tools. You should consult your own legal counsel, tax advisor or personal physician as applicable throughout your health care experience.

Out-of-network / non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

ATTENTION: If you speak a non-English language, call 833-905-1311 (TTY: 711) and you will be connected to an interpreter who will assist you at no cost.

The Blue FlexCard is issued by Stride Bank, N.A., Member FDIC, pursuant to license by Mastercard International. Stride Bank is an independent company offering debit card services and is solely responsible for its products.

Blue Cross NC contracts with independent companies to provide supplemental benefits. Those companies are responsible for the services they provide. They do not provide Blue Cross or Blue Shield products or services. Marks and trade names are property of their respective owners.

Change Healthcare is an independent company providing revenue and payment cycle management on behalf of Blue Cross and Blue Shield of North Carolina.

FitOn Health is an independent company providing health and fitness services on behalf of Blue Cross and Blue Shield of North Carolina.

CareLinx is an independent company providing in-home care solutions on behalf of Blue Cross and Blue Shield of North Carolina.

TruHearing is an independent company providing hearing health and hearing aids on behalf of Blue Cross and Blue Shield of North Carolina.

Current as of 09/25/2024 | Y0079_12996_M CMS Accepted 09252024

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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© 2024 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.