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2010 Medicare Part-D Formulary Coverage Changes


For the upcoming plan year 2010, changes are being made to the Blue Medicare HMOSM and Blue Medicare PPOSM (and BCBSNC's Blue Medicare RxSM) Part-D formularies, including the administrative process regarding coverage of certain drugs. More information, including coverage review criteria and fax request forms, can be found at www.bcbsnc.com/medicare.

Prior Authorization: Effective 1/1/2010, prior authorization will be required for the following drugs and drug classes:

  • Alfa interferons
  • Androgens and Anabolic Steroids
  • Colony Stimulating Factors
  • Erythroid Stimulants
  • Fentanyl transmucosal
  • Growth Hormones
  • Immune Globulins
  • Kineret® (anakinra)
  • LetairisTM (ambrisentan)
  • Orencia® (abatacept)
  • Provigil® (modafinil)
  • RevatioTM (sildenafil)
  • Rituxan® (rituximab)
  • AdcircaTM (tadalafil)
  • Thalomid® (thalidomide)
  • Tracleer® (bosentan)
  • Tumor Necrosis Factor (TNF) Inhibitors
In order to request coverage for any of these drugs, providers must complete and fax a prior authorization request form to BCBSNC. Fax numbers are included on the forms which are located at www.bcbsnc.com/medicare.

Step Therapy: Also effective 1/1/2010, coverage of non-preferred proton pump inhibitors and intranasal steroids will require step therapy. Going forward, reimbursement of non-preferred drugs in these categories will be considered only after a member's physician certifies in writing that the member has previously used a preferred proton pump inhibitor or intranasal steroid and such drug was ineffective in treating the condition or was detrimental to the member's health. Fax request forms can be found at www.bcbsnc.com/medicare.

Preferred Medications Non-preferred Medication*
(Physician Certification Required as of January 1, 2010)
Proton Pump Inhibitors (PPIs)
Omeprazole (generic Prilosec®)
Pantoprazole (generic Protonix®)
Nexium®
Proton Pump Inhibitors (PPIs)
Aciphex®
KapidexTM
Prevacid®
Protonix® packet for suspension
Zegerid®
Intranasal Steroids
Fluticasone (generic Flonase®)
Flunisolide (generic Nasarel®)
Nasonex®
Intranasal Steroids
Beconase AQ®
Nasacort® AQ
Rhinocort Aqua®
Veramyst®
Omnaris®

*Only the non-preferred drugs listed are subject to physician certification requirement.

Quantity Limitations: In addition, a number of drugs will have quantity limitations in plan year 2010. These quantity limits follow dosing guidelines for each drug approved by the Food and Drug Administration (FDA). The full list of drugs with quantity limitations can be found on www.bcbsnc.com/medicare.

If you have questions or need more information, please contact your regional Network Management representative.