Rx Utilization Management Changes Effective January 1, 2014
We want to inform you about the following new pharmacy utilization management requirements that will be effective January 1, 2014.
On the medical benefit, the following requirements will apply to commercial and State Health Plan members (does not apply to Federal Employee Program or Medicare Part D members):
Members will need to use one of the preferred medications, Synvisc/ SynviscOne or Euflexxa, before they can be approved to use one of the nonpreferred medications, which are Hyalgan, Gel-One, Orthovisc, or Supartz. Current and new users will need to submit authorization for the nonpreferred medications.
Tumor Necrosis Factors (TNFs)
A new drug, Simponi Aria, will be added to the list of medications requiring prior approval and quantity limit review. Additionally, Simponi Aria and Remicade will become preferred medications, which means that one of them must be tried first before Rituxan, Orencia or Actemra can be considered for approval. Current users will be grandfathered for this requirement and will not have to use a preferred medication first.
Under the pharmacy benefit, the following requirements will apply to all commercial members who have their pharmacy benefits with us. 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.
Tumor Necrosis Factors (TNFs)
In addition to current requirements for prior review and quantity limits, members must first try two of the following four preferred medications – Enbrel, Humira, Stelara or Simponi– before they can be approved to use the nonpreferred medications, which are Xeljanz, Cimzia or Orencia. Current users will be grandfathered for this requirement and will not have to use a preferred medication first.
Juxtapid and Kynamro
ALL members will need to obtain prior authorization and quantity limitation approval before using Juxtapid or Kynamro, which are medications used to treat homozygous familial hypercholesterolemia (HoFH).
ALL members will need to obtain prior authorization before using Vecamyl, which is a medication used to treat moderately severe to severe essential hypertension.
The prior review criteria for all androgens will be updated to reflect a change in the requirement of the laboratory testing for the diagnosis of hypogonadism. When submitting a request for one of these medications, please remember that lab values are a required part of this review.
Branded Angiotension Receptor Blockers (ARBs) will be added to the restricted access program. This means that the following drugs will be considered nonpreferred medications: Diovan, Azor, Benicar, Benicar HCT, Exforge, Exforge HCT, Micardis, Micardis HCT, Tribenzor, and Twynsta. Members must try a preferred generic ARB prior to receiving any of these nonpreferred ARBs.
The detailed review criteria for these pharmacy utilization management programs are available online at www.bcbsnc.com/umdrug.
If you have questions, please contact the Provider Blue LineSM at 1.800.214.4844.