Pharmacy Formulary Updates - Effective January 1, 2017

Below is a high-level summary of updates to Blue Cross and Blue Shield of North Carolina (BCBSNC) formularies that will be effective January 1, 2017. 

These updates apply to:

All members with pharmacy benefit coverage

All commercial members who have their pharmacy benefits with BCBSNC

 These updates do not apply to State Health Plan, Federal Employee Program, Medicare Part D members, or for any self-funded employer groups that carve out their pharmacy benefits to another pharmacy benefits manager.

New Formularies

BCBSNC will be implementing two new formularies, the Essential Formulary and the Net Results Formulary. Member ID cards will reflect which formulary they have; as of January 1, 2017, you can find the specifics on our website 

Both new formularies will be closed, meaning not all medications are covered. If a formulary medication has been ineffective or is contraindicated, and the member requires a nonformulary medication, there will be a nonformulary exception process. This will be explained on our website as of January 1, 2017.

For members who receive their benefits through the Health Insurance Marketplace (Affordable Care Act [ACA] policies), they will have a unique nonformulary exception process.

A standard nonformulary exception request must be processed within 72 hours of receipt of all information, and an urgent nonformulary exception request must be processed within 24 hours of receipt of all information.

In order to help us process these requests effectively, and not issue unnecessary denials, please be sure that all required information is submitted with the original request.

For these requests which result in a denial an external review process will be available.

We will continue to offer you a provider courtesy review and would encourage you to utilize this method first so that the external review is still available should a second denial be rendered.

If you submit additional information after a denial, BCBSNC will need you to identify which type of review you are seeking. This could be either a provider courtesy review performed by BCBSNC, or an external review. When submitting additional information, please clearly indicate the type of review you are requesting.

If an external review is requested first, a provider courtesy review will not be allowed.

 Additionally, ACA members may contact BCBSNC directly to initiate these requests. If they do this, BCBSNC will contact you for additional information needed to process these requests. 

Non-FDA Approved Medications

Effective January 1, 2017, BCBSNC will no longer provide coverage for non-FDA approved drugs. Many drug products are marketed in the United States illegally without required FDA approval. Often, healthcare providers and patients are unaware that drugs are not FDA approved. Some non-FDA approved drug products contain the same active ingredients as approved prescription drug products. However, they have not been tested by the FDA for correct strength, dose, quality, purity, and bioavailability as approved products. Drug labels may not disclose that the product is not FDA approved.

Member Cost Sharing Programs

BCBSNC will be reducing the number of medications that are part of two programs that eliminate member cost share on certain prescriptions. The drugs being removed consist of high cost brands and generics when there are suitable lower cost alternatives available. 

These programs are:

Medication Dedication, which provides coverage of certain medications with no member responsibility. Medications included in this program treat congestive heart failure, diabetes, high blood pressure and high cholesterol.

Enhanced Preventive HSA Benefits, which addresses conditions such as diabetes, high blood pressure, high cholesterol, osteoporosis and smoking cessation, among others. The definition of preventive is as follows:

Preventive drugs are those considered to be used for preventive purposes if it is being prescribed primarily (1) to prevent the symptomatic onset of a condition in a person who has developed risk factors for a disease that has not yet become clinically apparent or (2) to prevent recurrence of a disease or condition from which the patient has recovered. A drug is not considered preventive if it is being prescribed to treat an existing, symptomatic illness, injury or condition.

Lists of drugs which are part of the Enhanced Preventive HSA program will be updated on January 1, 2017, and can be found athttp://www.bcbsnc.com/content/services/formulary/preventive-rx-benefits.htm

Tier Changes

The following medications will be moved to higher tiers as noted below:

Androderm®1 – on formularies with 4 tiers or less, it will move from Tier 2 to Tier 3. On formularies with 5 tiers, it will move from Tier 3 to Tier 4.

Myrbetriq®1 – on formularies with 4 tiers or less, it will move from Tier 2 to Tier 3. On formularies with 5 tiers, it will move from Tier 3 to Tier 4.

Cuprimine®1 – on formularies with 4 tiers or less, it will move from Tier 2 to Tier 3. No impact to formularies with 5 tiers.

Depen®1 – on formularies with 4 tiers or less, it will move from Tier 2 to Tier 3. 
No impact to formularies with 5 tiers.

If you have any questions, please call the Provider Blue LineSM at 1-800-214-4844.