Rx Utilization Management Changes Effective July 1
We want to inform you about the following new pharmacy utilization management requirements that will be effective July 1, 2013.
Firazyr, a medication used to treat patients with hereditary angiodema, will require prior review when it’s received in the office or outpatient setting and filed under the member’s medical benefit. This new requirement applies to ALL commercial and State Health Plan users.
Firazyr has its own HCPCS code of J1744. It currently requires prior review under the member’s pharmacy benefit for those members who have Blue Cross and Blue Shield of North Carolina for their pharmacy benefits. This does not apply to State Health Plan members or ASO group members who have their pharmacy benefits with another pharmacy benefits manager.
Xeljanz (tofacitinib citrate)
The existing prior review requirements for Xeljanz, a medication used to treat adult patients with moderate to severe active rheumatoid arthritis, will now include the requirement that the patient has previously tried either Humira or Enbrel.
This requirement only applies to NEW users who have their pharmacy benefits with us. It does not apply to State Health Plan members or to members on any ASO employer groups that carve out their pharmacy benefits to another pharmacy benefits manager.
The detailed review criteria for both of these drugs are available for your review online at www.bcbsnc.com/umdrug.
These changes will be effective July 1, 2013, for the lines of business indicated above. Neither of these changes will apply to Federal Employee Program or Medicare Part D members.
If you have any questions, please contact the Provider Blue LineSM at 1.800.214.4844.