Skip to main content

Providers

Prescription drugs

   

Getting your patients' prescriptions covered

Most patients with Blue Cross and Blue Shield of North Carolina (Blue Cross NC) health insurance also have a medication plan to cover the medications they get at their pharmacy. Each medication plan comes with a list (or formulary) that shows you what medications are covered.

Are your patient's prescription medications covered?

  • Look for the "Rx" on their member ID card. It means they have medication coverage.
  • Look for a capital letter or a capital letter / number combination after the "Rx" on your patient's card. The letter will tell you which drug list, or formulary, your patient's plan uses. The number gives information about the pharmacies in your patient's network.
    • Enhanced Drug List: A, B
    • Essential Drug List: C, D
    • Net Results Drug List: E

Medications that need Prior Authorization

Some medications need additional information in writing from you before Blue Cross NC can decide if they 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.

To find a drug, use the search above or select a letter from the list above.

Words you may see in the drug search

Requesting medications not on your patient's Approved Medication List (Formulary)

For fastest processing, please submit requests online using CoverMyMeds, MHK Provider Portal, or SureScripts. If all details are submitted online and the request is approved, the member may be able to pick up their prescriptions at the pharmacy in less than 2 hours.

Processing methods include:

  • Pharmacy drug requests through these preferred online methods: CoverMyMeds.com⁠⁠, MHK Provider Portal (accessed via Blue e), or SureScripts.

    Or by fax at 800-795-9403.

    A pharmacy drug request is a medication that will be billed under a member’s pharmacy benefit (most tablets, capsules, topicals, at-home injections administered by the member, and items available at a retail pharmacy).

  • Medical drug requests submissions are preferred electronically through MHK Provider Portal (accessed via Blue e) only.

    Or by fax at 888-348-7332.

    A medical drug is a medication that will be billed under a member's medical benefit, including "buy and bill" scenarios (IV medications, injections administered in a provider’s office).

Once we have all required information, we'll make a decision within 3 business days and notify you. Requests are processed within 72 hours, unless urgent.

Urgent requests are handled within 24 hours. An urgent request is when you believe a delay would seriously jeopardize the life or health of the patient, the patient's ability to regain maximum function, or would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested.

Medications with limited or no plan coverage

Some medications may not be covered by the patient's plan or may have a limited amount the patient can receive. The following is a sample list of Drugs with Limited or No Coverage. Not all limited medications are listed.

For self-funded and ASO patients, you may need to call Blue Cross NC Customer Service for medication limits that may apply. If you are unsure if your patient's group is an underwritten or self-funded / ASO group, call the customer service number listed on the back of your patient's member ID card.

Brand-name drugs vs. generics

Don't let your patient over pay. They could be charged more if you prescribe a brand-name medication instead of a generic. If there's a medical reason the patient needs a brand-name medication, please:

  1. Check the Request for Waiver of Brand Drug Fees (PDF) to see if your patient meets our requirements.
  2. Send a Safety MedWatch Form to the FDA to tell them why your patient can't take the generic.
  3. Send us a Request for Waiver Faxback Form (PDF) with your patient's details.

Affordable Care Act (ACA) preventive drug list

Under the Affordable Care Act, some medications are covered at 100% on all prescription drug lists or formularies. These medications include aspirin, certain supplements, tobacco cessation support, and some contraceptives.


For drug and dosage details, refer to these lists:

Health savings account (HSA) preventive drug list

Some employer / group plans and all Individual – Under 65 plans include an HSA preventive drug coverage feature with members’ prescription benefit plan. The actual cost of the medication will be applied toward the preventive benefit offered, allowing members to receive coverage even if they have not met their deductible.

For drug and dosage details, refer to these lists: