Blue Cross and Blue Shield of North Carolina (Blue Cross ...

1 5154 NC Prime Therapeutics LLC 07 /22 Blue Cross Blue Shield of North Carolina Enhanced 4 tier Formulary July 2022 Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The medication formulary is regularly updated. Please visit for the most up-to-date information. Contents Preface .. I Member guide to covered medications on the Enhanced 4 tier Formulary .. I Enhanced Formulary tiers .. I 4- tier Formulary .. I 3- tier Formulary .. I 2- tier Formulary .. II Generic Medications .. II Compounded Prescriptions.

2 II Prior review , quantity limitations and restricted-access medications .. II Specialty medications .. III Affordable Care III Diabetic and Respiratory III Weight Loss .. III Medications with over the counter (OTC) therapeutic alternatives .. IV Limited Distribution medications .. IV Using the member guide to the Enhanced Formulary .. V Abbreviation key .. VI Therapeutic Class Medication List Anti-Infective Agents .. 1 Biologicals .. 15 Antineoplastic Agents .. 18 Endocrine and Metabolic Medications .. 26 Cardiovascular Agents .. 51 Respiratory Agents .. 75 Gastrointestinal Agents .. 82 Genitourinary Agents .. 90 Central Nervous System 93 Analgesics and Anesthetics .. 120 Neuromuscular Medications.

3 136 Nutritional Products .. 147 Hematological Agents .. 152 Topical Products .. 164 Miscellaneous Products .. 181 Index .. 194 To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) July 2022 Enhanced 4 tier Formulary I Member guide to commonly prescribed medications on the Enhanced Formulary This guide lists the approved brand name and generic prescription medications that have been reviewed by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Please refer to this formulary guide for information about medications covered by this formulary, and present this guide to your doctor if you require a prescription .

4 This guide was current at the time of printing and is subject to change. The prescription medications listed in the formulary or their tier placement may change from time to time due to a change in the cost of the medication and/or in the classification of the medication by the Food and Drug Administration (FDA) or nationally-recognized medication databases ( , Medispan). For a more complete listing of medication coverage and costs, you may use our Find a Drug search at You may also call Blue Cross NC Customer Service at the number listed on the back of your ID card to verify prescription medication benefits. A formulary is a list of prescription medications covered by a health plan. Blue Cross NC Pharmacy & Therapeutics (P&T) Committee reviews medications at least quarterly.

5 This includes ongoing reviews of clinical information about new medications and reviews of new safety and efficacy information about older medications. The majority of Blue Cross NC s P&T Committee is composed of practicing physicians and pharmacists independent of Blue Cross NC. tier placement of prescription medications in the formulary may be determined by: the effectiveness and safety of the medication, the cost of the medication, and /or the classification of the medications by the Food and Drug Administration (FDA) or nationally-recognized medication databases ( , Medispan). Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit design, out-of-pocket costs, prior review, quantity limitation and restricted access medications, and applicable exclusions.

6 Enhanced Formulary tiers The 3- tier and 4- tier Formularies cover most medications approved by the United States Food & Drug Administration (FDA), within existing benefits. The plan design determines the member s payment obligation. Some members have a two-tiered benefit structure ( tier 1 and tier 2), some members have a three-tiered benefit structure ( tier 1, tier 2, and tier 3), and some members have a four -tiered benefit structure ( tier 1, tier 2, tier 3, and tier 4) depending on the plan in which they are enrolled. 4- tier Formulary Definitions for a four -tiered benefit structure: tier 1: The prescription medication tier which consists of the lowest cost tier of prescription medications, most are generic.

7 tier 2: The prescription medication tier which consists of medium-cost prescription medications, most are generics, and some brand-name prescription medications. tier 3: The prescription medication tier which consists of higher-cost prescription medications, most are brand-name prescription medications, and some specialty medications. tier 4: The prescription medication tier which consists of the highest-cost prescription medications, most are specialty medications. 3- tier Formulary Definitions for a three-tiered benefit structure: tier 1: The prescription medication tier which consists of the lowest cost tier of prescription medications, most are generic. tier 2: The prescription medication tier which consists of medium-cost prescription medications, most are generics, and some brand-name prescription medications.

8 tier 3: The prescription medication tier which consists of higher-cost prescription medications, most are brand-name prescription medications, and some specialty medications. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) July 2022 Enhanced 4 tier Formulary II 2- tier Formulary Definitions for a two-tiered benefit structure: tier 1 tier 2, tier 3, tier 4 Generic medications In most cases choosing a generic medication equivalent, when available, may mean significant savings to you. We encourage you to discuss with your physician whether a generic alternative is available as these medications represent safe, effective treatment options. Especially for medications that are taken daily and refilled frequently, you will experience the long-term savings of a lower medication co-payment month after month.

9 For some benefit plans, if you choose a brand name prescription medication and a generic equivalent is available, you may be subject to a reduced benefit and a higher out-of-pocket expense. Compounded prescriptions Compounded prescriptions contain two or more medications mixed together. Compounded prescriptions are processed according to member benefits. To be eligible for coverage, compounded medications must contain at least one ingredient that is defined as a prescription medication and must not be a copy of a commercially available product. Compounded medications may be subject to prior review and benefit exclusion. Prior review, quantity limitations and restricted-access medications Under some benefit plans, certain medications may be subject to prior review, quantity limitations, or restricted-access programs.

10 BCBSNC s P&T Committee reviews the clinical criteria for these programs.. The different types of review include: Prior Review (PA)*: Your provider needs to review our clinical criteria and confirm that you meet the requirements. o A list of frequently used medications by drug class that will not be covered without prior authorization for medical necessity can be found here. If you continue to use one of these medications without prior approval for medical necessity you may be required to pay the full cost. If you are currently using one of these drugs ask your provider about the alternatives listed or visit the following website for criteria for approval: Quantity Limitations (QL)*: Your provider needs to review our clinical criteria and confirm that you meet the requirements for the amount requested.