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Rx Prior Review and Quantity Limit Changes Effective 10/1/2012

Release Date: June 29, 2012

We want to inform you of new utilization management programs that will be effective as of October 1, 2012 for Blue Cross and Blue Shield of North Carolina (BCBSNC) members enrolled in our commercial health care coverage products.  These new utilization management programs can be grouped into two categories:  those requiring prior review only, and those requiring prior review with a standard quantity limit.  These programs will impact all members who currently take these medications, as outlined below. 

PRIOR REVIEW 

Hereditary Angioedema therapy: Firazyr, Cinryze, Kalbitor, Berinert for ALL users. The detailed criteria for review of this medication can be found online at www.bcbsnc.com.  These therapies are sometimes very expensive and have specific FDA approved indications.  BCBSNC classifies Firazyr under a member’s pharmacy benefit only, while Cinryze, Kalbitor and Berinert are considered under a member’s medical benefit only.    

Repository corticotropin (H.P. Acthar Gel) for ALL users.  The detailed criteria for review of this medication can be found online at www.bcbsnc.com.  This program will be put in place due to the many indications and increased cost of the medication.  BCBSNC classifies H.P. Acthar Gel as a medical or pharmacy benefit.  

PRIOR REVIEW WITH A STANDARD QUANTITY LIMIT 

Fidaxomicin (Dificid) for ALL users.  The detailed criteria for review of this medication in the use of treatment of Clostridium difficile-associated diarrhea in adults can be found online at www.bcbsnc.com.  The standard quantity limit is 20 tablets per 10 days.  This program will be put in place due to its high cost and potential for being over prescribed.  BCBSNC classifies Dificid as a pharmacy only benefit.

Oxycodone HCL extended-release (OxyContin) for ALL users. The standard quantity limit of 2 tablets per day for the 10mg, 15mg, 20mg, 30mg, 40mg, and 60mg strengths will be applied as well as a quantity limit of 4 tablets per day for the 80 mg strength.  The quantity limit is based on the FDA approved dosing of OxyContin. This program will be put in place due to the increase reports of abuse and overprescribing of this medication.  BCBSNC classifies OxyContin as a pharmacy only benefit.

Capsaicin 8% Patch (Qutenza) for ALL users. The detailed criteria for review of this medication can be found online at www.bcbsnc.com.  The standard quantity limit is 4 patches every 90 days.  This program was put in place due to the fact the drug requires physician application and patient safety monitoring.  BCBSNC classifies Qutenza as a medical only benefit.

These pharmacy utilization management changes will apply all commercial members who have their pharmacy benefits with BCBSNC.  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.  Medications that fall under the medical benefit will apply to all BCBSNC members except Federal Employee Program and Medicare Part D members.

If you have any questions, please contact our BCBSNC Network Management specialists at 1.800.777.1643, or BCBSNC Customer Service via the Provider Blue LineSM at 1.800.214.4844.