If the medication is listed in the Drug Search, these requirements may also apply.
Check to see if the new medication is on the medication list.Consider if there's another medication they could take.If you want your patient to take a medication that isn't on the Essential or Net Results medication list, here's what to do: 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. Urgent requests are handled within 24 hours. Requests are processed within 72 hours, unless urgent. Once we have all required information, we'll make a decision within 3 business days and notify you. Mail: Blue Cross NC, Attn: Corporate Pharmacy, PO Box 2291, Durham, NC 27707.Online (Preferred - for Providers Only): Some drugs if approved can be ready at the pharmacy in less than 2 hours.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. 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. 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.Get a Quote for Individual and Family PlansĪncillary and Specialty Benefits for Employees.Health Plans for Individuals and Families.
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