Humira ), Certolizumab Pegol (Cimzia

Change in Prior Review Requirements for etanercept (Enbrel®), adalimumab (Humira®), certolizumab pegol (Cimzia®) and golimumab (Simponi®) Effective October 1, 2011, coverage of Enbrel, Humira, Cimzia and Simponi will include quantity limitations. DRUG CLASS: Disease Modifying Anti-Rheumatic Drug (DMARD) DRUG NAMES: Etanercept (Enbrel) Adalimumab (Humira) Certolizumab pegol (Cimzia) Golimumab (Simponi) Effective October 1, 2011, coverage of ENBREL will include the following quantity limitations: The allowed quantity for maintenance doses is four 50 mg injections every 28 days or eight 25 mg injections every 28 days. This corresponds to maintenance doses of 50 mg per week. For patients with psoriasis who may require higher doses for the first 12 weeks of therapy, eight 50 mg injections every 28 days may be approved for the first 12 weeks of therapy. Effective October 1, 2011, coverage of HUMIRA will include the following quantity limitations: The allowed quantity for maintenance doses of Humira is two 40 mg injections every 28 days. This corresponds to maintenance doses of 40 mg every other week. (Maintenance quantity limits will not take effect until 30 days after initiation of therapy.) For patients with rheumatoid arthritis who are not taking concurrent methotrexate, four 40 mg injections every 28 days are allowed. Effective October 1, 2011, coverage of CIMZIA will include the following quantity limitations: The allowed quantity for maintenance doses is two 200 mg injections every 28 days. This corresponds to maintenance doses of 400 mg every 28 days or 200 mg every other week. (Maintenance quantity limits will not take effect until 30 days after initiation of therapy.) Effective October 1, 2011, coverage of SIMPONI will include the following quantity limitations: The allowed quantity is one 50 mg injection every 30 days. These new requirements are in addition to the current prior review criteria for Enbrel, Humira, Cimzia and Simponi. Please see http://www.bcbsnc.com/content/providers/ppa/prescriptions.htm for information on current criteria. Note: the fax request forms for Enbrel, Humira, Cimzia and Simponi will change effective October 1, 2011. Change in Coverage for desvenlafaxine (Pristiq®) for new users Effective October 1, 2011, Blue Cross and Blue Shield of North Carolina (BCBSNC) is changing the administrative process regarding coverage of desvenlafaxine (Pristiq), a serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressant. Reimbursement of Pristiq for new users will be considered only after a member’s physician certifies in writing to BCBSNC that the member has previously used the preferred agent venlafaxine (Effexor®/XR or generic), and venlafaxine was ineffective in treating the condition or was detrimental to the member’s health. 1NON-PREFERRED MEDICATION: PREFERRED MEDICATION Physician certification required as of October 1, 2011 SNRI ANTIDEPRESSANTS PREFERRED DRUG TRIED: NONPREFERRED DRUG REQUESTED: venlafaxine (generic or brand Pristiq (desvenlafaxine) Effexor or Effexor XR) Members will be notified of this change by early September 2011. After October 1, if a member who is new to Pristiq attempts to fill a prescription for Pristiq, the claim will reject at the pharmacy as prior review/certification by BCBSNC will be required. As a result of the claim rejection, the member may contact their physician to discuss if a preferred option would be appropriate for their condition. If the physician believes that the non-preferred medication is necessary, the physician must submit the above-referenced written certification to BCBSNC for review. Fax request forms will be available on the Web on or before October 1, 2011. .

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