By Counterforce Health Team in Humira (adalimumab) —

Get Humira (Adalimumab) Approved by Blue Cross Blue Shield North Carolina: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Humira Approved by BCBS North Carolina

Blue Cross Blue Shield of North Carolina requires prior authorization for Humira (adalimumab) with step therapy through preferred biosimilars first. Submit PA via the Availity Provider Portal or call 800-672-7897. Include clinical documentation of biosimilar failures, diagnosis codes, and medical necessity. If denied, file internal appeals within 180 days, then escalate to North Carolina's Smart NC external review program for binding decisions within 45 days.

First step today: Check your formulary tier at MyPrime.com and gather records of any prior adalimumab biosimilar trials or contraindications.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Required Forms for Prior Authorization
  3. Submission Portals & Electronic Options
  4. Fax & Mail Submission Details
  5. Specialty Pharmacy Network Requirements
  6. Member Services & Support Contacts
  7. North Carolina Appeals & External Review
  8. When to Update Your Resources

Verify Your Plan & Find the Right Forms

Before starting your Humira prior authorization, confirm your specific Blue Cross NC plan type and formulary. Different plans have varying requirements:

Plan Types & Coverage

Plan Category Formulary Humira Status Biosimilar Preference
Commercial NetResults 4-5 Tier Non-preferred, PA required Amjevita, Cyltezo, Hadlima preferred
Health Insurance Marketplace Essential Q/QS Restricted Access/Step Therapy Must try biosimilars first
Healthy Blue Medicare Medicare formulary Tier 4-5 specialty Step therapy applies

Check your specific plan: Log into MyPrime.com with your member ID to view your exact formulary and tier placement for Humira.

Current Policy Requirements (2024-2025)

Blue Cross NC requires trial and failure of up to two preferred adalimumab biosimilars before approving brand Humira, unless you have documented contraindications or clinical history showing biosimilars would cause harm.

Note: As of July 2023, Blue Cross NC added multiple adalimumab biosimilars to preferred status, making step therapy the primary hurdle for Humira approval.

Required Forms for Prior Authorization

Core Documentation Needed

Clinical Records Required:

  • Confirmed diagnosis with ICD-10 code (e.g., M05.9 for rheumatoid arthritis, L40.5 for psoriatic arthritis)
  • Prior therapy history: dates, doses, durations, and outcomes for biosimilar trials
  • Disease severity measures and treatment goals
  • Required screenings: TB test, hepatitis B panel, CBC, liver function tests
  • Prescriber attestation with NPI and specialty designation

Step Therapy Documentation

To bypass biosimilar requirements, provide evidence of:

  • Previous biosimilar failures: Include specific adalimumab biosimilars tried (Amjevita, Cyltezo, Hadlima, Simlandi), trial duration (minimum 3 months), and reasons for discontinuation
  • Contraindications: Document allergies or medical conditions preventing biosimilar use
  • Clinical stability: If switching from Humira, show evidence that interruption would risk disease flare

Medical Necessity Letter Checklist

Your prescriber's letter should include:

  • Patient's specific diagnosis and disease activity scores
  • Complete prior treatment history with DMARDs and biologics
  • Clinical rationale for Humira over biosimilars
  • Expected treatment outcomes and monitoring plan
  • Reference to FDA labeling or specialty guidelines supporting use

Submission Portals & Electronic Options

Primary Electronic Submission: Availity Portal

Availity (Blue e® Portal) is Blue Cross NC's primary provider portal for PA submissions:

  • URL: availity.com
  • Access: Providers log in with Blue Cross NC credentials
  • Features: Electronic PA submission, status tracking, document upload
  • Timeline: Standard decisions within 15 business days, expedited within 72 hours

Submission Steps:

  1. Log into Availity and select "Prior Authorization"
  2. Use "Add a medicine" dropdown to find Humira/adalimumab
  3. Complete clinical questionnaire with required documentation
  4. Upload supporting files (lab results, prior therapy records, medical necessity letter)
  5. Submit and track status through portal

Alternative Electronic Options

CoverMyMeds Integration:

  • Available for some Blue Cross NC plans
  • Check CoverMyMeds BCBSNC forms for electronic PA options
  • Streamlines submission for participating providers

Fax & Mail Submission Details

Phone Submission for Urgent Cases

Utilization Management: 800-672-7897

  • Hours: Monday-Friday, 8 AM-5 PM ET
  • For: In-network providers requesting expedited review
  • Timeline: Urgent decisions within 24 hours, standard within 72 hours

Fax Submission Process

  1. Download drug-specific forms from the Blue Cross NC prescription drug search tool
  2. Complete Value Prior Authorization Request Form with all clinical documentation
  3. Fax to numbers listed on forms (verify current fax numbers on downloaded forms)
  4. Include cover sheet with member ID, prescriber NPI, and "URGENT" notation if expedited
Tip: Always call to confirm fax receipt within 24 hours of submission, especially for time-sensitive requests.

Specialty Pharmacy Network Requirements

Network Participation Requirement

Blue Cross NC mandates specialty pharmacy network use for Humira coverage. Self-administered specialty drugs like Humira must be filled through participating pharmacies to ensure coverage and access to clinical support services.

Participating Specialty Pharmacies

  • ADVance Care Pharmacy
  • Amber Specialty Pharmacy
  • Biologics by McKesson
  • BioPlus Specialty Pharmacy
  • CareMed Specialty Pharmacy
  • CenterWell Specialty Pharmacy
  • CVS Specialty
  • FountainRx
  • Lumicera Health Solutions
  • Maxor Specialty Pharmacy

Free Market Health (FMH) Program

For eligible commercial plans, Blue Cross NC's FMH program automatically matches approved PAs to network specialty pharmacies through competitive bidding:

  • Eligible plans: Fully insured ACA, commercial, non-ERISA ASO/MEWA plans
  • Process: Assigned pharmacy contacts prescriber directly after PA approval
  • Benefits: Faster delivery, reduced abandonment, competitive pricing

Enrollment Process

  1. Obtain PA approval through standard submission process
  2. Verify network pharmacy by calling member services at 877-258-3334
  3. Transfer prescription to assigned or preferred network pharmacy
  4. Complete pharmacy enrollment including insurance verification and delivery preferences

Member Services & Support Contacts

Primary Contact Numbers

General Member Services: 877-258-3334

  • Customer service in English and Spanish
  • Plan verification and benefits questions
  • General coverage inquiries

Specialty Drug Services: 877-275-9787

  • Specialty medication information
  • Network pharmacy guidance
  • Coverage verification for biologics

Prior Authorization Status: 877-727-3784

  • PA request status updates
  • Submission confirmation
  • Timeline inquiries

Provider Support Lines

Provider Blue Line: 800-214-4844

  • Provider-specific support
  • Claims and authorization assistance
  • Technical portal support

Utilization Management: 800-672-7897

  • PA submissions and status
  • Peer-to-peer review requests
  • Clinical review discussions

Case Management Services

Health Management: 888-234-2415

  • Complex case coordination
  • Specialty drug case management
  • Care plan development
When to call: Contact case management if you're managing multiple chronic conditions or need coordination between specialists and your specialty pharmacy.

North Carolina Appeals & External Review

Internal Appeals Process

First Level Internal Appeal:

  • Deadline: 180 days from denial notice
  • Timeline: 15 business days for standard, 72 hours for expedited
  • Submission: Via Availity portal, fax, or mail with additional clinical evidence

Second Level Internal Appeal:

  • Timeline: 15 business days for final internal decision
  • Requirements: New or additional medical evidence supporting necessity

North Carolina External Review

Smart NC Program - North Carolina Department of Insurance:

  • Phone: 855-408-1212 (free advocacy and guidance)
  • Timeline: 120 days after final internal denial to request external review
  • Decision period: 45 days for standard review, 72 hours for expedited
  • Cost: Free to consumers
  • Binding: IRO decisions are binding on insurers

External Review Eligibility

  • State-regulated plan (not self-funded employer plans unless opted in)
  • Denial based on medical necessity or experimental treatment determination
  • Exhausted internal appeals (or qualify for expedited review)

Expedited External Review: Available when delay would seriously jeopardize life or ability to regain function. Smart NC can waive internal appeal requirements for urgent cases.

Smart NC Support Services

The Smart NC program provides free assistance with:

  • Completing external review request forms
  • Gathering medical records and supporting documentation
  • Communicating with insurers during the review process
  • Finding clinical guidelines and medical literature to support cases

When to Update Your Resources

Regular Update Schedule

Quarterly Reviews (every 3 months):

  • Check formulary changes at MyPrime.com
  • Verify specialty pharmacy network updates
  • Review PA form versions on Blue Cross NC provider portal

Annual Reviews:

  • Confirm plan enrollment and benefits
  • Update prescriber and pharmacy contact information
  • Review any changes to North Carolina external review procedures

Trigger Events for Updates

  • Plan year changes (typically January 1)
  • Formulary updates (often mid-year)
  • New biosimilar approvals or preferred drug changes
  • Changes in North Carolina insurance regulations
Pro tip: Bookmark the Blue Cross NC prescription drug search tool and check it before each PA submission to ensure you're using current requirements.

Frequently Asked Questions

How long does Blue Cross NC prior authorization take for Humira? Standard PA decisions take up to 15 business days. Expedited reviews for urgent cases are completed within 72 hours. Call 800-672-7897 to request expedited review if delay would jeopardize your health.

What if Humira isn't on my formulary? Submit a non-formulary exception request with documentation showing preferred biosimilars failed or are contraindicated. Include medical necessity letter and complete prior therapy history.

Can I appeal step therapy requirements? Yes. Provide evidence of biosimilar failures, contraindications, or clinical stability concerns with brand Humira. Submit appeals through Availity portal or call 877-727-3784.

Does step therapy apply if I was stable on Humira in another state? Document your treatment history and stability on Humira. Blue Cross NC may grant exceptions for patients with established therapeutic response to brand product.

What's the cost difference between Humira and biosimilars? Biosimilars typically have lower copays due to preferred formulary status. Check your specific plan's tier structure at MyPrime.com for exact cost differences.

How do I find my assigned specialty pharmacy? Call 877-275-9787 after PA approval to identify your network specialty pharmacy options. Some plans use the FMH program to automatically assign pharmacies.

Counterforce Health helps patients and clinicians navigate complex insurance appeals by turning denials into targeted, evidence-backed requests. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and procedural details to maximize approval chances.

For comprehensive support with Blue Cross NC appeals and other insurance challenges, visit CounterforceHealth.org to learn how we help streamline the prior authorization process.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and is not medical advice. Coverage decisions depend on your specific plan, medical history, and clinical circumstances. Always consult your healthcare provider for medical decisions and verify current requirements with Blue Cross Blue Shield of North Carolina. For personalized assistance with North Carolina insurance issues, contact Smart NC at 855-408-1212.

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