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Medicare

Prescription drug coverage limitations and exclusions

Some drugs covered by Medicare may have additional requirements or limits on coverage.

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.

    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. 

    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. 

    Use the Drug Search

    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.