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Pharmacy Updates Effective January 1, 2018

Effective January 1, 2018, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have changes to our pharmacy utilization management (UM) requirements.

Our UM requirements apply to all commercial members with pharmacy benefit coverage through Blue Cross NC. These changes do not affect State Health Plan, Federal Employee Program, Medicare Part D members, or any self-funded employer groups that carve out pharmacy benefits to another pharmacy benefits manager (PBM).

Below is a summary of the changes, and more details can be found here.

Pharmacy (UM) Changes

The following requirements apply to medications which are on a Blue Cross NC formulary. If a medication listed below is not on one of the Blue Cross NC formularies, the criteria referenced below will need to be met, as well as possible other requirements. Nonformulary requirements will be noted in the drug specific criteria found online.

Fortamet and generic metformin ER osmotic release – this program deals with preferring medications that are therapeutically equivalent, but not comparable in price. Costs for this medication have consistently increased over time, and this program is an effort to meet patients' medical needs, while minimizing costs.

  • Fortamet (metformin ER osmotic release) and its generic are therapeutically equivalent to Metformin ER (Glucophage XR).
  • However, total costs can be as much as 10 times higher.
  • Therefore, patients on the Enhanced and Net Results formularies taking Fortamet or its generic will be subject to prior approval and step therapy. Please note: this requirement went live for the Essential formulary, which includes the ACA population, in October 2017.
  • Alternatives without UM requirements include metformin ER, the generic of Glucophage XR.

Adding medications / requirements to existing UM programs:

  • Brand Lodine will be added to the Oral NSAID UM program, and will be subject to step therapy on Enhanced and Essential formularies.
  • Brand Lopid will be added to the Fibrate UM program, and will be subject to step therapy on all formularies.

Updating current UM programs which will only affect NEW USERS:

  • Abstral, Fentora, Lazanda and Subsys will have the additional requirement of the trial and failure of generic Actiq (step therapy), before approval will be given.
  • Biologics – the following table identifies preferred and non-preferred medications per disease state:

FDA Indication

Preferred Medications

Non-preferred Medications

Rheumatoid Arthritis (RA)1

Injectable: Enbrel, Humira, Simponi

Oral: Xeljanz, Xeljanz XR

Actemra, Cimzia,  Kevzara, Kineret, Orencia

Psoriatic Arthritis2

Cosentyx, Enbrel, Humira, Simponi, Stelara

Cimzia, Orencia

Plaque Psoriasis2

Cosentyx, Enbrel, Humira, Stelara

Siliq, Taltz, Tremfya

Ankylosing Spondylitis2

Cosentyx, Enbrel, Humira, Simponi

Cimzia

Crohn’s Disease3

Humira and Stelara

Cimzia

Ulcerative Colitis

Humira and Simponi

Polyarticular Juvenile Idiopathic Arthritis3

Enbrel and Humira

Actemra, Orencia

  1. Requires trial and failure of 2 preferred injectable medications then a preferred oral medication prior to any non-preferred medications
  2. Requires trial and failure of 3 preferred medications prior to any non-preferred medications
  3. Requires trial and failure of 2 preferred medications prior to any non-preferred medications
  • Desoxyn and Evekeo, when used for the treatment of ADHD, will have the additional requirement of trying and failing generic ADHD products (step therapy).
  • Forteo will have the additional requirement of the trial and failure of Tymlos for appropriate indications (step therapy), before approval will be given.
  • Sporanox solution will be added to the Oral Antifungal program, and will be subject to prior approval on all formularies.
  • Testosterone products will require new users to have two lab values submitted in order to confirm the diagnosis of low testosterone.

If you have any questions, please call the Provider Blue LineSM at (800)214-4844.