Limits on prescription drug coverage
Prior authorization, step therapy, and quantity limits are types of restrictions on prescription drug coverage. You find out if a drug requires further review in the member's plan formulary or by using the drug search.
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.
- Blue Medicare Rx Standard (PDF)
- Blue Medicare Rx Enhanced (PDF)
- Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete (PDF)
- Blue Medicare HMO Employer Group MAPD, Blue Medicare PPO Employer Group MAPD (PDF)
- Blue Medicare Rx Employer Group HCE (PDF)
- Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced (PDF)
Step therapy is a program that requires members to first try one drug to treat their condition before Blue Cross NC will cover another drug for that condition.
Quantity limits are restrictions our plan puts on the amount of the drug that we will cover per perscription. 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.
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Search for drugs with coverage limitations
The easiest way to find the appropriate fax form and criteria for your plan is to use our search tool.
Limitations and exclusions
Our Medicare prescription drug coverage has rules to ensure the quality of members' care.
Excluded drugs
Our plans use a prescription drug formulary.1 Benefits are limited to the drugs on this formulary unless an exception is approved by the plan.
- 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
You can find more information in your Evidence of Coverage.
Limitations
For Blue Medicare Advantage HMO, Blue Medicare Advantage PPO, and Blue Medicare Rx PDP:
- Certain drugs have quantity limits.
- Certain drugs require prior authorization.
- Certain drugs require step therapy.
- Compounded medications require an exception request to be approved.
- Drug benefits or services not described in the plan formulary or the Evidence of Coverage, or not required by law or regulations, are not covered.
- Drugs covered by Medicare Part B are not payable as Part D benefits. (Refer to your Medicare Part B coverage documents for Part B drug coverage.)
- If a Medicare beneficiary is eligible for Part D and does not sign up in the initial enrollment period, a Medicare late enrollment penalty may apply.
- Medications cannot be refilled before 75% of the time period for the supply has passed. For example, if the prescription is written for a 30-day supply, then you may obtain a refill beginning on the 23rd day.
- Members must use network pharmacies to receive full benefits.
- Plan benefits and premium are subject to change annually.
- Prescriptions filled by pharmacies outside the United States, even for a medical emergency are not covered.
- Prescriptions filled prior to effective date of coverage or after disenrollment date are not covered.
- Replacement of lost or stolen prescriptions are not covered.
- The plan's contract may be canceled by either the plan or the Centers for Medicare & Medicaid Services.
- All claims must be received within 3 years of the fill date. For example, if a drug is purchased on January 31, 2024, the claim must be received no later than January 31, 2027. Claims received after this time frame will not be eligible for coverage.
For Blue Medicare Advantage HMO and Blue Medicare Advantage PPO:
- An exception request for a Tier 5 (Specialty Tier) drug to be paid at the brand or generic cost sharing level is not permissible under this plan.
- Enhanced coverage gap drug benefits: In the coverage gap, you pay only a copayment for Tier 6 preferred generics and 25% coinsurance for all other generics. Your coinsurance for approved brand-name drugs is 25%.
- Standard coverage gap drug benefits: In the coverage gap, you pay 25% coinsurance for all generics. Your coinsurance for approved brand-name drugs is 25%.
- Members enrolled under this plan may not have drug coverage through both a Medicare Part D prescription drug plan and a Medicare supplemental plan.
- To enroll in a Blue Medicare HMO or Blue Medicare PPO plan, you must reside within the CMS approved service area.
For Blue Medicare Rx PDP:
- An exception request for a Tier 5 (Specialty Tier) drug to be paid at the lower cost-sharing level is not permissible under this plan.
- Enhanced coverage gap drug benefits: In the coverage gap, you pay a copayment for Tier 1 preferred generics and 25% coinsurance for all other generics.
- Standard coverage gap drug benefits: In the coverage gap, you pay 25% coinsurance for all drugs (brand or generic).
- If you are already enrolled in a Medicare Supplement or Medicare Advantage plan that includes Part D drug coverage, you should not enroll in a stand-alone PDP Part D prescription drug plan.
- To enroll in Blue Medicare Rx, you must reside within North Carolina. If you are in prison, you cannot join this plan.
Disclosures:
Blue Cross and Blue Shield of North Carolina is an HMO, HMO-POS, PPO and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.
Blue Cross and Blue Shield of North Carolina Senior Health DBA Blue Cross and Blue Shield of North Carolina is an HMO-POS D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.
Blue Medicare Supplement plans offered: [Plan A: BMS A, 1/24, Plan G: BMS G, 1/24, Plan HI DED G: BMS HDG, 1/24, Plan K: BMS K, 1/24, Plan N: BMS N, 1/24.]
Blue Medicare Supplement is not endorsed by or affiliated with the United States Government or the federal Medicare program.
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.
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Formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
Current as of 07/12/2024 | Y0079_12318_M CMS Accepted 08282024 | U36079, 6/24
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