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Change in Coverage for SSRI Antidepressants, Triptans, and Hypnotic Agents


Effective April 1, 2010, Blue Cross and Blue Shield of North Carolina (BCBSNC) is changing the administrative process regarding coverage of the non-preferred selective serotonin reuptake inhibitors (SSRIs), migraine therapy drugs (triptans), and hypnotic agents identified below. Going forward, reimbursement of these drugs will be considered only after a member's physician certifies in writing to BCBSNC that the member has previously used at least one preferred selective serotonin reuptake inhibitor (SSRI), migraine therapy drug (triptan), and hypnotic agent and such drug was ineffective in treating the condition or was detrimental to the member's health. (Certification will be required for new users of a non-preferred SSRI antidepressant, but will not be required for members who are already taking a non-preferred SSRI antidepressant.) On or after March 22, 2010, physicians may begin submitting written certification to BCBSNC by completing and faxing the review form for the drug in question that will be found on our Web site at bcbsnc.com on the Provider page.

1NON-PREFERRED MEDICATIONS:
Physician certification required as of April 1, 2010
PREFERRED MEDICATIONS
2SSRI Antidepressants: NON-PREFERRED MEDICATIONS:
  • Lexapro
  • Luvox CR
  • Pexeva
SSRI Antidepressants: PREFERRED MEDICATIONS
  • Citalopram HBr (generic Celexa)
  • Fluoxetine HCl (generic Prozac or Sarafem)
  • Fluvoxamine maleate (generic Luvox)
  • Paroxetine HCl (generic Paxil)
  • Sertraline (generic Zoloft)
Migraine Therapy (Triptans): NON-PREFERRED MEDICATIONS:
  • Amerge
  • Axert
  • Frova
  • Treximet
  • Zomig, Zomig ZMT
Quantity Limitations may also apply to all triptans.
Migraine Therapy (Triptans): PREFERRED MEDICATIONS
  • Sumatriptan (generic Imitrex)
  • Rizatriptan (Maxalt, Maxalt MLT)
  • Eletriptan (Relpax)
Oral Bisphosphonate
  • Ambien CR
  • Edluar
  • Lunesta
  • Rozerem
  • Zolpimist
A benefit limit may also apply to hypnotic agents.
Hypnotics: PREFERRED MEDICATIONS:
  • Zaleplon (generic Sonata)
  • Zolpidem (generic Ambien)

1 Only the non-preferred drugs listed are subject to physician certification requirement.
2
Certification will not be required for patients already taking a non-preferred SSRI antidepressant (prescription claim within the past 12 months). Members will be notified of this change by March 1, 2010. After April 1, if a member attempts to fill a prescription for a non-preferred drug, the claim will reject at the pharmacy as prior review/certification by BCBSNC is required (an exception will be made for patients already taking a non-preferred SSRI antidepressant — see above). As a result of the claim rejection, the member may contact their physician to discuss if a generic or preferred brand option would be appropriate for their condition. If the physician believes that the non-preferred medication is necessary, the physician must submit the above-referenced written certification to BCBSNC for review.