Coverage Authorization for Active Employees Enhanced PPO Plan (80/20)
Some prescription drugs may require coverage authorization: prior approval, step therapy and/or quantity limits. It is 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.
A medication may also be covered under the medical benefit and can be given in a medical office, in that situation providers should contact Blue Cross and Blue Shield of North Carolina at 888-234-2416 for approval.
Prior Approval
Drugs requiring prior approval have detailed criteria that must be met before prior authorization can be granted.
Step Therapy
Step Therapy requires the trial and failure of one or more prerequisite drugs before the step therapy medication will be covered. Step therapy promotes the appropriate use of equally effective but lower cost drugs, most often generics, as first line therapy.
Quantity Limits
Some prescription drugs may be subject to quantity limits, based on criteria developed by the State Health Plan or its representative. Prior approval is required before excess quantities of certain drugs will be covered.
If you need quantities in excess of the limit for a drug that is subject to quantity limits, it is important to make sure your provider has received prior authorization before you go to the pharmacy.
Coverage Authorization Drug List: Prior Approval, Step Therapy and Quantity Limit
You can search for drugs that require prior approval, step therapy, and or quantity limits using our online drug listing and search tool.
Provider Instructions
To initiate and/or complete prior authorizations (coverage reviews) with CVS, providers have several options available.
Access ePA through a web-based portal or an EHR-integrated solution. Choose one below.
Secure online portal - Registration takes only a few minutes and there is no cost for prescribers.
EHR Integration
Another option to initiate and/or complete a coverage review case is to contact CVS Caremark coverage review department at 800-294-5979, 24 hours a day, seven days a week.