Prime Therapeutics Pa Form – Fill Out and Use This PDF

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Effective January 1, 2012, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and Health Options, Inc. will expand our Responsible Rx pharmacy program for BlueCare, BlueChoice and BlueOptions. Responsible Rx refers to an umbrella of programs including Prior Authorization, Responsible Step and Responsible Quantity programs. Members with endorsements that support these programs may be affected.

Prior Authorization

Effective January 1, 2012, the medications listed below will require prior authorization for coverage under the member’s pharmacy benefit.

Oral Oncology

The intent of the Oral Oncology Agents Prior Authorization (PA) program is to ensure appropriate selection of patients for treatment according to product labeling and/or clinical studies and clinical guidelines. Patients currently prescribed therapy with one of these agents will be able to continue their established therapy. New prescriptions after January 1, 2012 will require review.

Pharmaceutical compendia [National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium, American Hospital Formulary Service (AHFS) Drug Information, DrugDex, and Clinical Pharmacology] may be consulted to evaluate for medically accepted off-label use. Prior Authorization requests for oral oncology agents will be reviewed when patient-specific documentation is provided.

BCBSFL will also be classifying these oral oncology medications as specialty pharmacy medications, effective January 1, 2012. BCBSF’s preferred specialty pharmacy provider is CVS Caremark Specialty Pharmacy. CVS Caremark’s toll free number is 1-866-278-5108. Some members may pay a higher out

of pocket cost share when using an out-of-network pharmacy for specialty medications.

New Drugs to Existing Programs

Orencia subcutaneous® (abatacept)

Orencia subcutaneous will be added to our Immunomodulators PA program.

Prior authorization request forms are available on the provider website at www.bcbsfl.com under For Providers, then Pharmacy, and the Prior Authorization Program Information and Authorization forms link.

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Responsible Rx Expansion

QUESTIONS AND ANSWERS

Responsible Quantity

QUESTION: Why are there limits on the quantity that I can get on my prescription?

ANSWER: BlueCross and BlueShield of Florida has established quantity limits or coverage maximums for certain medications based on manufacturers and FDA approved dosing guidelines.

QUESTION: Will there be limits on all of my medicines?

ANSWER: Only medications included in the Responsible Quantity Program have quantity limits.

QUESTION: My doctor said I had to have this many pills. What can I do?

ANSWER: Responsible Quantity does not prevent you from receiving the medicine your doctor has prescribed for you. The program places a coverage maximum on select medicines filled in a 30-day period. If your doctor prescribed a greater quantity of the medicine for you, we will cover the Responsible Quantity maximum quantity for your usual copayment or coinsurance, and you may pay for the remainder of the quantity prescribed by your doctor. However, if your doctor determines you must have a greater quantity than the limit, your doctor can request an authorization from BlueCross and BlueShield of Florida to have a greater limit covered for you.

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Responsible Steps

QUESTION: I received a letter that said I would no longer have coverage for my medication unless I have tried a generic first. I do not like to use generics because I have read that they are not as effective as brand drugs.

ANSWER:

Generic drugs are FDA-approved and proven to be safe and effective for treating certain conditions. Please check with your doctor if a generic drug is right for you.

QUESTION: I have asked my doctor about generics and he/she put me on the brand drug that you are no longer covering. What can I do?

ANSWER: Check with your doctor if a generic drug is right for you. If not, authorization forms for drugs in our Responsible Steps program are available on our website. Your doctor will fill out the form and fax it in for review. Forms are available at www.bcbsfl.com under providers, then pharmacy, then Responsible Steps Program Information and Authorization Forms.

QUESTION: I have taken the prerequisite meds in the past, but it has been longer than the time period required in the responsible steps program. Can I still qualify for coverage?

ANSWER: In order for your claim for a responsible steps drug to be covered, you will need to have a claim for a prerequisite drug within the last 90 days.

QUESTION: It says that current users will not be affected by this step. Does this mean that no matter what, I can still get my prescription filled?

ANSWER: No. In order for your claim for your drug to be covered, you will need to have a claim in our system for a prerequisite drug within the last 90 days. In other words, you have to keep refilling your prescription regularly.