Pharmacy Resources
Blue Cross and Blue Shield of Nebraska's Pharmacy Services Department, in collaboration
with our pharmacy benefit manager Prime Therapeutics, LLC., develops programs
and resources to inform both physicians and their patients, our members, about
the appropriate, cost-effective use of pharmaceuticals. Given the rising cost
of healthcare, some groups have chosen to implement programs that promote appropriate
therapy through pharmacy pre-authorization programs.
Migraine Quantity Maximum Program
This program places a monthly quantity maximum on the benefits for acute migraine
medications. This affects the brand name medications Amerge, Axert, Cafergot,
DHE, ergotamine, Frova, Imitrex, Maxalt, Midrin, Migranal NS, Relpax, Stadol NS
and Zomig. Maximum monthly quantities vary by the medication and dosage form.
Please review the Migraine Quantity Maximum Pre-Authorization Program
medical
criteria. It may be necessary for you to complete and submit a pre-authorization form to obtain benefits above the quantity maximum for acute migraine medications.
COX-2 Inhibitors Pre-Authorization Program
The COX-2 Inhibitors PA program affects benefits for COX-2 inhibitors, which only
affects the drug Celebrex. This product has been selected for pre-authorization
because of its overuse and expense relative to other medications used in the treatment
of pain and arthritis. The program requires that a patient have risk factors that
may put them at an increased risk of complications for the use of a non-selective
NSAID. These risk factors include age over 65, a history of peptic ulcer disease,
GI bleeding, GI obstruction, GI perforation or concurrent contraindicated therapies.
Please review the COX-2 Pre-Authorization Program medical
criteria. It may be necessary for you to complete and submit a pre-authorization form to determine
if continued COX-2 benefits are available.
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Injectable Psoriasis Medication Pre-Authorization Program
This program affects benefits for the non-formulary brand name medications Amevive and Raptiva.
These drugs have been selected for pre-authorization because the majority of patients
experiencing active disease can be successfully managed with less costly topical
or systemic therapy. The program requires a patient to have tried either topical
or systemic options, along with the formulary products Enbrel and Humira before Amevive or Raptiva will be covered.
Please review the Injectable Psoriasis Pre-Authorization Program criteria for
Amevive or Raptiva.
It may be necessary for you to complete and submit a pre-authorization
form to determine if benefits for these medications are available.
Asthma Ig-E Inhibitor Pre-Authorization Program
This program affects benefits for the brand name medication Xolair. Xolair has
been selected for pre-authorization because other therapeutic options, including
inhaled corticosteroids, are the most effective and cost-efficient option for
most patients. The program requires other therapies to be optimized before Xolair will be covered.
Please review the Xolair Pre-Authorization Program criteria. It may be necessary
for you to complete and submit a pre-authorization form to determine if benefits
for this medication are available.
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Leukotriene Modifier Pre-Authorization Program
This program affects the benefit of Singulair and Accolate. These products have
been selected for pre-authorization because inhaled or nasal corticosteroids
have been demonstrated to be first line agents for the treatment of asthma and
seasonal allergic rhinitis. This program requires the concurrent use of inhaled
or nasal corticosteroids with either Singulair or Accolate.
Please review the Leukotriene Modifier Pre-Authorization Program criteria. It
may be necessary for you to complete and submit a pre-authorization form to determine
if benefits for these medications are available.
Proton Pump Inhibitor Pre-Authorization Program
This program affects the benefit of non-formulary proton pump inhibitors, currently
Kapidex, Nexium, Prevacid, Protonix, Prilosec and Zegerid. These products have been selected for
preauthorization because of their similar clinical effectiveness and safety.
The main difference between these products is their cost. Therefore, members
are required a trial of all formulary products prior to use of a non-formulary agent.
Please review the Proton Pump Inhibitor Pre-Authorization Program criteria.
It may be necessary for you to complete and submit a pre-authorization form to
determine if benefits for this medication are available.
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Retinoids (Topical Acne Agents) Pre-Authorization Program
This program affects the benefit of a class of topical acne agents called Retinoids
(Avita®, Differin®, Retin-A®, Retin-A Micro®, Tazorac® and tretinoin)
for patients over the age of 40 years. These products have been selected
since their primary indication for acne vulgaris is seldom seen past this age.
In patients over the age of 40, these products are used for facial wrinkles,
which is an uncovered benefit. Members must be under the age of 40 to be eligible for automatic coverage.
Please review the Retinoid (Topical Acne Agents) Pre-Authorization criteria.
It may be necessary for you to complete and submit a pre-authorization form to
determine if benefits for this medication are available.
Growth Hormone Pre-Authorization Program
The Growth Hormone Pre-Authorization Program is intended to optimize the utilization of growth hormone supplementation in conditions where efficacy has been established and in those patients identified through product labeling and clinical guidelines. Growth hormone has been selected for pre-authorization (PA) due to the strict product labeling and use in off-label conditions that can be considered cosmetic (i.e., anabolic therapy to enhance body mass or strength for professional, recreational, or social reasons). The medications included in the Growth Hormone PA Program are Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-Tropin, and Zorbtive. The program requires medical documentation of specific conditions where there is a deficiency in growth hormone, conditions where height is improved regardless of growth hormone deficiency, and conditions that are improved by the addition of growth hormone to the medication regimen.
Beginning July 1, 2009, the use of the formulary product Omnitrope™ will be required prior to the use of any other growth hormone product. The step program has been targeted due to the availability of a lower cost product with identical active ingredients.
Please review the Growth Hormone Pre-Authorization Program medical
criteria. It will be necessary for a healthcare provider to complete and submit a
pre-authorization form to determine if benefits for the requested medication are available.
Specialty Drug Benefit
The PrimeRxSpecialty program provides a convenient, cost-effective way for you
to order specialty medications for delivery directly to your home or physician’s
office. Specialty medications are typically self-administered injectable drugs
used to treat serious or chronic medical conditions such as multiple sclerosis,
hemophilia, hepatitis and rheumatoid arthritis. The PrimeRxSpecialty medication
list outlines the products designated as specialty medications.
Please refer to your Certificate of Coverage and/or Schedule of Benefits to
determine the specific coverage and quantities allowed under your plan. If you
have additional questions, contact Blue Cross and Blue Shield of Nebraska Customer
Service Center at the number on the back of your ID card.
Enroll in the PrimeRxSpecialty program by completing the Specialty Medication
Enrollment form.
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Synagis Pre-Authorization Program
This program affects the benefit for Synagis. This product has been selected
to ensure patients prescribed therapy meet the selection requirements defined
in product labeling and/or clinical guidelines and/or clinical studies. Well-defined
guidelines for choosing eligible patients have been established by the American Academy of Pediatrics and have been updated in 2009.
Please review the Synagis Pre-Authorization Program criteria. It will be necessary
for you to complete and submit a pre-authorization form to determine if benefits
for this medication are available.
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