Traditional Pharmacy Benefits

Drugs Requiring Prior Approval, Step Therapy and/or Quantity Limits*

*These policies apply to the Traditional 70/30 Plan, Enhanced 80/20 Plan and Consumer-Directed Health Plan (CDHP).

Pharmacy

Some prescription drugs may require prior approval, step therapy and/or be subject to quantity limits. It is very important to make sure that prior approval is received before filling your prescription.

The State Health Plan may change the list of prescription drugs that require prior approval, step therapy and/or are subject to quantity limits at any time.

If a medication may also be covered under the medical benefit and the drug will be given in the medical office, physicians should contact Blue Cross and Blue Shield of North Carolina for approval (these medications are marked with an asterisk* on the Prior Approval Chart).

If you disagree with a decision made during the prior authorization process, you have the right to request that the State Health Plan or its representative review the decision through the grievance process. This process is voluntary and may be requested by the member or an authorized representative acting on the member's behalf. For more information on this process, please visit PPO Plan Grievance.

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