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80/20 Plan for Non-Medicare Retirees
Coverage Authorization Program: Drugs Requiring Prior Approval, Step Therapy and/or Quantity Limits

shp_prior_auth-pharmacist400.jpgSome prescription drugs may require Coverage Authorization: prior approval, step therapy  and/or 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.

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 

shp_pharmacist400.jpgSome 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, prescribers have several options available. First, prescribers with a username and password can log on to Caremark.com‚Äč to view existing coverage review cases for their patients, initiate a coverage review case for their patients (a rejected pharmacy claim must be on file in order to initiate a case), or complete a coverage review case (answer the coverage criteria questions required to determine coverage).

If a prescriber does not have or does not know their username and password, please call CVS at 888-321-3124, 8 a.m. to 9 p.m., Eastern Time, Monday through Friday, and a username and password will be provided. Another option to initiate and/or complete a coverage review case is to contact CVS coverage review department at 888-321-3124, 24 hours a day, seven days a week.