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Drug Prior Approval and Quantity Limitations Now Include PPO and POS

March 3rd, 2004

Effective March 1, 2004, we are expanding our prescription drug Prior Approval (PA) and Quantity Limitation (QL) programs to include our Preferred Provider Organization (PPO) and Point-of-Service (POS) lines of business, in addition to our HMO products. These programs will apply to Blue Care®, Blue Choice® and Blue OptionsSM.

The Quantity Limitations program is a concurrent drug utilization program that encourages the appropriate use and dosage of a prescribed drug based upon the U.S. Food and Drug Administration’s approval and supporting medical literature. Drugs currently subject to quantity limits include Triptans (e.g., Amerge and Imitrex), Stadol, Toradol, Diflucan, Proton Pump Inhibitors and Hypnotics.

Prior Approval is a program that applies to specific drugs that are prescribed for a narrow list of conditions. The PA program requires that BCBSNC obtain the diagnosis and certain necessary clinical information before the drug is approved for payment. Drugs that currently require prior approval include growth hormones, botulinum toxins, certain antifungals, COX-2 inhibitors and DMARDs.

Requests for prior approval for any of the above prescription drugs or requests for quantity limit considerations for patients that exceed the dosage limits should be directed to our Medical Resource Management department at 1-800-672-7897. You can also refer to our Web site at bcbsnc.com for the most up-to-date information regarding drugs that are subject to the Prior Approval and Quantity Limitation programs.