Effective July 1, 2010, Blue Cross and Blue Shield of NC is implementing changes to its prior/review certification and restricted access drug lists that will impact approximately 18,000 members with pharmacy benefits through BCBSNC. Described below, these changes involve prior review of three injectable drugs, and the restriction/up-tiering of several angiotensin receptor blockers (ARBs), all of which are currently covered under BCBSNC medical benefits.

Prior Review/Certification Changes
The following injectable drugs will now require prior review by BCBSNC and written certification from a prescribing physician to determine medical necessity:

• Synagis® (palivizumab), used to prevent respiratory syncytial virus (RSV) prophylaxis in infants and children at risk
• Actemra® injections (tocilizumab), used to treat rheumatoid arthritis
• Stelara® injections (ustekinumab), used to treat psoriasis

Up-Tiering and Restricted Access Drug List Changes Regarding ARBs
The following ARBs (used most often for treating hypertension) are being added to the BCBSNC restricted access drug list and will also require written certification of prescribing physician: Atacand®, Atacand-HCT®, Avapro®, Avalide®, Benicar®, Benicar-HCT®, Teveten®, and Teveten-HCT®.

In addition, all of these ARBs will be moved from Tier 2 to Tier 3 of the BCBSNC prescription drug formulary on July 1, which may result in a higher copayment for affected members.

Notification of Affected Members
BCBSNC has already begun notifying affected members, and the sample letters are available for download.

Please note that most infants and very young children who receive Synagis® for one RSV season will not require it for a second season. Using past claims to identify patients who may require RSV prophylaxis for the upcoming RSV season will not be effective.  For this reason, BCBSNC will not send letters to affected patients or their caregivers.

Should you have any questions regarding these changes, please contact our office at 919-403-1986.