BCBSNC to Initiate New Pharmacy Management Programs October 1
Beginning October 1, 2009, Blue Cross Blue Shield of NC is expanding its prior review/certification requirements for several drugs to create new pharmacy management programs for covered members. These new programs will require action on the part of members to seek prior review/certification for certain medications. The following is a brief summary of these changes:
Prior Review/Certification for Intranasal Steroids
This program requires users of non-preferred intranasal steroids (Beconase AQ, Nasacort AQ, Rhinocort Aqua, and Veramyst) for treatment of allergic rhinitis to try generic Flonase or Nasonex before the non-preferred drug will be covered.
Prior Review/Certification for Oral Bisphosphonates
This program requires users of non-preferred bisphosphonate (Actonel) for treatment or prevention of osteoporosis to try generic Fosamax, Fosamax D or Boniva before the non-preferred drug will be covered.
New Proton Pump Inhibitor (PPI) Prior Review/Certification
This program requires new users of non-preferred PPIs (such as Prevacid or Zegerid) for treatment of acid reflux or heartburn to try two of the preferred PPI options (omeprazole, pantoprazole, or Nexium) before the non-preferred drug will be covered. Currently, BCBSNC requires members to try only one of the preferred PPI options before a non-preferred drug will be covered.
New Drug for Rheumatoid Arthritis Added to Prior Review/Certification List
BCBSNC is adding Simponi, a new drug used to treat rheumatoid arthritis, to the existing prior review program for disease-modifying antirheumatic drugs. This will require affected members to try methotrexate before Simponi is covered.
To advertise these new programs, BCBSNC is currently mailing letters to members who are currently prescribed one of the non-preferred intranasal steroid or oral biphosphonate drugs. Because Simponi is a new medication and no members are currently using the drug, no notification will be made to users of antirheumatic drugs.
Members should note that if prior review/certification is not obtained for these drugs on or after October 1, 2009, any attempt to fill a prescription for one of the drugs will result in rejection of the claim. As a result of the claim rejection, the member may be directed to contact their prescribing provider to discuss other treatment options that would be appropriate for his or her condition.
Members with questions regarding this new prior review/certification requirement can access a Frequently Asked Questions document or call BCBSNC Customer Service at the toll-free number listed on their ID card. Should you have any additional questions about these new programs, please contact our office at 919-403-1986.
Important Notice: Hill, Chesson & Woody does not engage in the practice of law, accounting, or medicine. Therefore, the contents of this communication should not be regarded as a substitute for legal, tax, or medical advice.
September 3, 2009
Hill, Chesson & Woody
Employee Benefit Services
194 Finley Golf Course Road, Suite 200,
Chapel Hill, NC 27517
Phone: 919.403.1986
Fax: 919.869-2063
www.hcwbenefits.com