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Rx Prior Review and Quantity Limit Changes - Effective 1/1/2013

Release Date: September 24, 2012

We want to inform you about some new utilization management programs that will be effective January 1, 2013, for Blue Cross and Blue Shield of North Carolina (BCBSNC) members who have their pharmacy benefits with us.  These programs all fall under the pharmacy benefit.  Details of the changes for first quarter 2013 are outlined below:

  • Compounded drugs costing more than $200 will require prior review for ALL users. An analysis of our members’ claims history indicates that many compounds can be effectively substituted with commercially available medications that may be available to the member at a lower cost.  
  • Suboxone and Subutex (or generic buprenorphine SL tablets) will require prior review and be subject to quantity limitations for ALL users. Even though this medication is used for opioid dependence, many individuals are abusing these therapies.  As a reminder, only addiction-trained specialists with an “X” in their DEA number are allowed to prescribe this medication.
  • Topical Androgens will continue to require prior review, but Androderm and Androgel will become the preferred drugs.  Members who are currently using the nonpreferred products will not be required to change to the preferred Androderm or Androgel.  If you want to prescribe any other medications for your BCBSNC patient, the member must try or have tried these preferred medications first. 

In addition to the above changes for January 2013, there are new weight- loss drugs currently being released to market.  Qsymia is now available, and Lorcaserin will be released in the near future.  Both of these drugs are or will be subject to prior review as they are officially released. 

These pharmacy utilization management changes will apply to all commercial members who have their pharmacy benefits with us.  However, these changes will not apply to State Health Plan, Federal Employee Program, Medicare Part D members, or for any ASO employer groups that carve out their pharmacy benefits to another pharmacy benefits manager.  Detailed criteria regarding pharmacy prior review guidelines and quantity limitations, along with related faxback forms for your convenience, are available online at

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