Three Drugs added to Prior Review list as of July 1
Effective July 1, 2009, prior review is required for coverage of alefacept injection (Amevive) and for transmucosal fentanyl (Actiq, Fentora).
In order to request coverage for Amevive or for transmucosal fentanyl, providers must complete and fax the appropriate prior review fax form to BCBSNC. The form can be downloaded from our Web site at www.bcbsnc.com via the Provider portal.
Criteria for coverage of Amevive are outlined in a new medical policy that is available online in the "Medical Policy" section. The patient must have moderate to severe plaque psoriasis, be at least 18 years of age, have received phototherapy (or is not a candidate for phototherapy), and have received other systemic treatments for psoriasis before coverage for Amevive will be considered. Please see the medical policy for more detail. If approved, Amevive is covered under BCBSNC's medical benefits.
Transmucosal fentanyl formulations will also require prior review for coverage. Drug products containing fentanyl designed to be absorbed through the buccal mucosa include fentanyl citrate lozenges (Actiq and generics) and fentanyl buccal tablets (Fentora).
There is no specific medical policy on the use of this drug as the criteria for coverage of transmucosal fentanyl follows FDA-approved indications:
- Patients must have breakthrough pain due to cancer.
- Patients must be receiving chronic opioid therapy, preferably with a long-acting opioid formulation.
- Patients are considered opioid tolerant when any of the following doses are used, for one week or longer:
- at least 60 mg morphine/day
- at least 25 mcg transdermal fentanyl/hour
- at least 30 mg of oxycodone daily
- at least 8 mg oral hydromorphone daily
- an equianalgesic dose of another opioid
- treatment of acute or postoperative pain
- patients who are not taking chronic opiates
- patients who are not opioid-tolerant
- patients with hypoxia or hypercarbia
Fentanyl citrate lozenges (Actiq and generics) and fentanyl buccal tablets (Fentora) are covered under BCBSNC's pharmacy benefits.