February 23, 2018
North Carolina Department of Insurance
Consumer Services Division
325 N. Salisbury Street
Raleigh, NC 27603-1359
Complainant:
Maggie M.
NCDOI File Number:
Subscriber ID:
Subscriber Policy:
Effective Date:
Member Policy Type:
Grandfathered:

90
Blue Local Bronze 5500-OFF
1/1/17 and currently active
Individual
No

To the Department of Insurance Consumer Services Division:
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is writing in response to
the open correspondence(s) regarding the NCDOI File Number for the complainant
shown above. Thank you for the opportunity to review this matter.
The Department writes requesting documentation that would advise of the specific
conditions for approval to lower a drug's cost. The Department asks specifically about
the following language in the member’s benefit booklet:
“From time to time, MEMBERS may receive a reduced or waived copayment and/or
coinsurance on designated drugs in connection with a program designed to reduce
PRESCRIPTION DRUG costs.”
The language sited above is standard in most Blue Cross NC benefit booklets and is
used to permit Blue Cross NC to provide “from time to time . . . . a program designed to
reduce Prescription Drug Costs.” These are not set programs and they are not
consistently available. When Blue Cross NC launches such a program, we provide
ample direct mail pieces and use other avenues to alert members to these programs. An
example of such a program Blue Cross NC has offered in the past was related to a
copay waiver for generic drugs. Currently, Blue Cross NC is not offering any such
programs.
Therefore, Ms. XX is limited to the current benefit design for her pharmacy benefits and
any exceptions that are currently laid out in her member booklet. As previously stated,
the member’s benefits include a brand name penalty fee in cases where the generic
drug is available. The benefit booklet language highlights the possibility of requesting an
exception to the policy. This request to waive the contractual brand drug penalty is the
provider’s responsibility. The following steps must be completed in order for the request
to be considered:


The provider must submit the Request for Waiver of Brand Drug Additional Fees
for review. Per the documentation included in our previous responses, “Additional
fees may be waived for a brand name medication when a generic is available if
all of the following are met:
Post Office Box 2291 • Durham, North Carolina 27702-2291
An Independent Licensee of the Blue Cross and Blue Shield Association

 1. The prescriber has indicated on the prescription “Dispense As Written
(DAW)”; AND
2. The patient has tried an AB-rated generic equivalent to a brand name
medication; AND
3. The patient had a documented allergic reaction to an excipient (inactive
ingredient) that is present in the generic formulation, but is absent in the
brand name equivalent; AND/OR
4. The patient had a documented life-threatening side effect that required
medical intervention to a generic medication that did not occur with the
brand; AND
5. The prescriber completed and submitted an FDA MedWatch Adverse
Event Reporting Form “[the prescriber must provide a copy of the
completed MedWatch; authorization will not be considered unless the
form is completed and submitted to the FDA].”
This information is also highlighted at BlueCrossNC.com: “Difference between brand and
generic drugs - depending on your benefits, you may be charged more if you receive a
brand drug when a generic is available. We may not ask you to pay the difference if
there is a medical reason you need to take the brand name drug. There are some steps
you must take:



Your provider should send in a document to the Food and Drug Administration to
let them know you cannot take the generic and why. You can find more
information and the form to submit at http://www.fda.gov/Safety/MedWatch
Your provider should review the previously attached criteria, and if you meet
these guidelines, they can then submit information via this fax form or through
CoverMyMeds.”

Blue Cross NC records show that we received the provider’s request on 2/20/18. Per the
attached denial letter dated 2/21/18, “Requests for waiver of brand-name drug additional
fees may be granted when the member has tried an AB-rated generic equivalent and
had either a documented allergic reaction or life-threatening side effect that did not occur
with the brand equivalent. In this case, none of the above criteria are met.”
Blue Cross NC offers an appeals process for our members. Appeals must be submitted
in writing by the member, or the member’s representative, with the member’s written
permission. The appeal must be filed within 180 days of the denial to be eligible for
review.
If the member has any questions or concerns, they may contact customer service at
1-888-206-4697.
Please be advised the enclosed response contains member protected health
information. This response is intended for the North Carolina Department of Insurance
(NCDOI) and is not intended for further distribution.
If the Department needs further assistance on this matter, please contact us through the
portal.
Sincerely,
Post Office Box 2291 • Durham, North Carolina 27702-2291
An Independent Licensee of the Blue Cross and Blue Shield Association

 Corporate Compliance
Blue Cross NC, NAIC 54631

Post Office Box 2291 • Durham, North Carolina 27702-2291
An Independent Licensee of the Blue Cross and Blue Shield Association