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Important Information Regarding Drug Utilization Management Effective January 1, 2014

We want to help you prepare for upcoming changes regarding our members’ benefits, and we’ve prepared some tools to help you navigate the system to successfully ensure our members / your patients obtain the medications necessary for their optimum health.  These tools will help you to:

·         Understand the different prescription drug formularies available January 2014.

·         Know where to go online to get the most helpful and up-to-date information regarding pharmacy utilization management.

·         Ensure your requests are answered as quickly as possible.


All of the information below is also available online for your reference at

Rx Formularies for 2014

As of January 1, 2014, Blue Cross and Blue Shield of North Carolina (BCBSNC) will offer four formularies:

·         Enhanced 4-Tier:  This is our current, standard open formulary, which is based on a plan with a four-tier copayment benefit design.

·         Enhanced 5-Tier:  This is a new open formulary similar to the 4-Tier with the same drug utilization management requirements.  It differs in that it has an additional copayment benefit tier, so there are two copayment levels for generic drugs.

·         Basic Closed:  This is our current, closed formulary.  Some drugs are nonformulary and require an exception process review in order to be covered.

·         Basic Open:  This is a new, open formulary with medications that were nonformulary on the Basic Closed, which are added back to the formulary with some type of drug utilization management requirement (i.e., prior review, quantity limitation, and / or restricted access/step therapy).


The member’s ID card will identify his or her plan type.  In general, this equates to the formulary listed below.  Because of the recent changes made to the Affordable Care Act that allows members to keep the health plan they currently have, members who had a plan as of October 1, 2013, when the Exchange went live are able to keep and renew their plans, if they choose to do so.  The following chart explains what that looks like regarding the prescription drug formularies:


Benefit Plan

Enhanced 4-Tier

Plans that had this benefit prior to 2014-- including Blue Care®, Blue Advantage®, Blue OptionsSM (all types), Blue SaverSM, Individual Blue OptionsSM HSA

Enhanced 5-Tier

New individual plans (Blue Advantage, Individual Blue Options HSA) effective 1/1/14

Basic Closed 5-Tier

Plans that had this benefit prior to 2014, including Blue ValueSM / Blue SelectSM

Basic Open 5-Tier

New Blue Value / Blue Select plans effective 1/1/14 or after


Pharmacy Utilization Management Information Online

Our website, is the one-stop place you can go to find the information you need, such as:

·         Identify which members require review for which drugs.

o   The above table and other helpful hints are located here.

·         Criteria and fax forms now updated to accommodate all formularies.

o   Please use this Web page as your reference for all pharmacy utilization management criteria and related fax forms, as many documents were recently updated to reflect changes that bring them in line with our new formularies.

·          How to submit your request for authorization.

o   How to submit your requests, as well as helpful telephone contact information.

o   Please keep in mind that when you submit a fax form for us to review, all required information must be completed on the form.  This includes all demographic information about the patient, you as a provider, all questions related to the medication in question, as well as the prescribing provider’s signature.  If any of this information is missing, it will delay the review process and decision regarding the medication.  No one wants to delay a request, so please help us by providing all required information on the fax form when you submit it to us for review.


 If you have any questions, please contact the Provider Blue LineSM at 1.800.214.4844.