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Change in Intranasal Steroids, Oral Bisphosphonates and Proton Pump Inhibitor Coverage


Effective October 1, 2009, Blue Cross and Blue Shield of North Carolina (BCBSNC) is changing the administrative process regarding coverage of the nonpreferred intranasal steroids and oral bisphosphonates 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 a preferred intranasal steroid or oral bisphosphonate and such drug was ineffective in treating the condition or was detrimental to the member's health. On or after September 21, 2009, physicians may begin submitting written certification to BCBSNC by completing and faxing the review form for the drug in question that can be found on our Web site at bcbsnc.com on the Provider page.

Preferred Medications Nonpreferred Medication* (Physician Certification Required as of October 1, 2009)
Intranasal Steroids
fluticasone (generic Flonase)
Nasonex
flunisolide (generic Nasarel)
Intranasal Steroids
Beconase AQ
Nasacort AQ
Rhinocort Aqua
Veramyst
Omnaris
Oral Bisphosphonate
alendronate (generic Fosamax)
Fosamax D
Boniva
Oral Bisphosphonate
Actonel

*Only the nonpreferred drugs listed are subject to physician certification requirement.

Members will be notified of this change by September 1, 2009. After October 1, if a member attempts to fill a prescription for a nonpreferred drug, the claim will reject at the pharmacy as prior review/certification by BCBSNC is required. 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 nonpreferred medication is necessary, the physician must submit the above-referenced written certification to BCBSNC for review.

Additionally, the administrative process regarding coverage of nonpreferred proton pump inhibitors (PPIs) will be changing effective October 1, 2009. Going forward, reimbursement of these drugs will be considered only after a member’s physician certifies in writing that the member has previously used two preferred PPIs and such drugs were ineffective in treating the condition or were detrimental to the member's health. The current administrative process requires the use of one preferred PPI. This process change will only affect new PPI users effective October 1, 2009.

Preferred Medications Nonpreferred Medication* (Physician Certification Required)
Proton Pump Inhibitor
omeprazole (generic Prilosec®)
pantoprazole (generic Protonix®)
Nexium®
Proton Pump Inhibitor
Zegerid®
Prevacid®
Protonix® (40mg suspension only)
Prilosec® (oral suspension only) Lansoprazole® powder for compounds Aciphex® KapidexTM

*Only the nonpreferred drugs listed are subject to physician certification requirement.

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