Important News

2010 Medicare Part-D Formulary Coverage Changes

For the upcoming plan year 2010, changes are being made to the Blue Medicare HMO^SM and Blue Medicare PPO^SM (and BCBSNC's Blue Medicare Rx^SM) 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)
Letairis^TM (ambrisentan)
Orencia® (abatacept)
Provigil® (modafinil)
Revatio^TM (sildenafil)
Rituxan® (rituximab)
Adcirca^TM (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® Kapidex^TM 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.