Most patients with 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. Show
Are your patient's prescription medications covered?1) Look for the "Rx" on their member ID card. It means they have medication coverage. 2) 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 Essential Drug List Net Results Drug List How to Find Your Patient's Approved Medication List or Formulary1) Return to the Providers homepage
2) On the Find a Doctor, Drug or Facility page
You'll go to Prime Therapeutics, our pharmacy benefit manager's website. Your patient's medication list, or formulary, search should look like this: 3) Type a medication name in the blue search box, select the formulation and strength you are prescribing and click Submit.
Medications that Need Prior AuthorizationSome 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. Enter a drug name in the search box to see if it needs approval before it's covered by a patient's plan. Or click the first letter of your drug to view lists: To find a drug, use the search above or select a letter from the list above. Brand Drug Name: {{header}}
No results found for '{{header}}' Prior AuthorizationProviders must explain in writing why patients need a certain medication before Blue Cross NC can decide if it will be covered. Quantity LimitsTo encourage the proper use of prescription medications, Blue Cross NC may restrict the amount of medicine an insurance plan covers. This may mean taking fewer pills each day without changing the total strength of the medication. Step TherapyBlue Cross NC requires that patients first try a medication or device that is not restricted before a restricted medication will be approved. Patients may be covered for a restricted medication if providers tell Blue Cross NC in writing that: The patient has already used the non-restricted medication and it wasn't effective in treating the condition; or The provider thinks the non-restricted medication is likely to be harmful to the patient's health or not effective in treating their condition. Non-formularyA non-formulary medication is one that isn't on a patient's Blue Cross NC medication list. Not all medication lists or formularies have non-formulary medications. Providers must confirm that a patient has tried the medication(s) on their list first, and that they were ineffective or harmful. Also, any medication-specific clinical criteria must be met before approval (available in the Drug Search). Specialty DrugsMay be used to treat a complex or rare condition, and are generally:
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. In-network pharmacy options vary based on the patient's plan benefits. Important: If your patient has changed health plans, you may need to tell us that your patient has met the rules for their new plan. For Patients with an Essential Medication List (Formulary): If your patient meets the Criteria for Approval of Restricted Products (pdf), and their list says that Prior Review (Prior Authorization) or Step Therapy is required for a medication, but the medication isn't in the Drug Search, please send a request to Blue Cross NC using this General Authorization Fax Form (pdf). Requesting Medications Not on Your Patient's Approved Medication List (Formulary)For fastest processing, please submit requests online using CoverMyMedsTM. 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. Other processing methods include:
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. 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:
For members on the Essential Medication List (formulary), if request for a non-formulary medication is approved, these cost levels or "tiers" will apply: Essential 5 Tier = Tier 5 For members on the Net Results Medication List (formulary), if the request for a non-formulary medication is approved, these cost levels or "tiers" will apply: Non-specialty medication = Tier 4 Medications with Limited or No Plan CoverageSome medications may not be covered by the patient's plan or may have a limited amount the patient can receive. The Table of Drugs with Limited or No Coverage shows a sample listing. 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. GenericsDon'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:
Does insurance cover Ozempic weight loss?Insurance won't cover Ozempic, Rybelsus and Wegovy for Weight Loss? Since the medication semaglutide was first developed for the treatment of type 2 Diabetes, many insurances still will not cover the prescription, brand name or generic, for weight loss.
How do I get Ozempic weight loss?Ozempic may be covered partially by your insurance. With some commercial insurance plans, you may be eligible to pay as little as $25 when you receive a prescription for either a 1-month or 3-month supply. Unfortunately, many insurance plans do not cover Ozempic at all.
Is there a generic for Ozempic?Ozempic (semaglutide) is used to improve blood sugar control in adults with type 2 diabetes. There are currently no generic alternatives for Ozempic.
Are Wegovy and Ozempic the same?What's the difference between Ozempic® and Wegovy®? Both Ozempic® and Wegovy® are the same medication: semaglutide. Wegovy®, however, is available in slightly higher doses: 0.25 mg, 0.5 mg, 1.0 mg, 1.7 mg, and 2.4 mg pens. Ozempic® is available in 0.25 mg, 0.5 mg, and 1.0 mg pens.
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