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Enhanced Value Program – Enhanced
| Restricted Non-preferred Product(s) | Unrestricted/Suggested Alternative(s) |
|---|---|
| Basaglar (insulin glargine) Glargin yfgn (unbranded Semglee biosimilar) Insulin Glargine (unbranded Lantus biosimilar) Insulin Glargine (unbranded Toujeo biosimilar) Insulin Degludec (unbranded Tresiba biosimilar) Rezvoglar (insulin glargine-aglr) | Lantus (insulin glargine) Semglee (insulin glargine-yfgn) Toujeo (insulin glargine) Tresiba (insulin degludec) |
| SymlinPen (pramlintide injection) | Novolin/Novolog (insulin isophane) |
| Bexagliflozn (authorized generic Brenzavvy) Brenzavvy (bexagliflozin) Dapagliflozin (authorized generic Farxiga) Dapagliflozin/Metformin (authorized generic Xigduo XR) Inpefa (sotagliflozin) Invokana (canagliflozin) Invokamet (canagliflozin/metformin) Invokamet XR (canagliflozin/metformin) Segluromet (ertugliflozin/metformin) Steglatro (ertugliflozin/l-pyroglutamic acid) | Farxiga (dapagliflozin) Jardiance (empagliflozin) Glyxambi (empagliflozin/linagliptin) Trijardy XR (empagliflozin/linagliptin/metformin) Synjardy (empagliflozin/metformin) Synjardy XR (empagliflozin/metformin) Xigduo XR (dapagliglozin/metformin) |
| Aloglipitin Cycloset (bromocriptine) Nesina (aloglipitin) Onglyza (saxagliptin) Saxagliptin (generic Onglyza) Sitagliptin (Zituvio) Tradjenta (linagliptin) Zituvio (sitagliptin) | Farxiga (dapagliflozin) Januvia (sitagliptin) Jardiance (empagliflozin) |
| Alogliptin/metformin Alogliptin/pioglitazone Jentadueto/Jentadueto XR (linagliptin/metformin) Kazano (alogliptin/metformin) Kombiglyze XR (saxagliptin/metformin) Oseni (alogliptin/pioglitazone) Saxagliptin/metformin (generic Kombiglyze XR) Sitagliptin/metformin Zituvimet/Zituvimet XR (sitagliptin/metformin) | Janumet (sitagliptin/metformin) Janumet XR (sitagliptin/metformin) Synjardy (empagliflozin/metformin) Synjardy XR (empagliflozin/metformin) Trijardy XR (empagliflozin/linagliptin/metformin) Xigduo XR (dapagliglozin/metformin) |
| Qtern (dapagliflozin-saxagliptin) Steglujan (ertugliflozin/sitagliptin) | Glyxambi (empagliflozin/linagliptin) Trijardy XR (empagliflozin/linagliptin/metformin) |
| Tudorza Pressair (aclidinium bromide) | Incruse Ellipta (umeclidinium bromide) Spiriva HandiHaler / Respimat® (tiotropium bromide) |
| Albuterol HFA (authorized generic Ventolin HFA) ProAir Digihaler (albuterol sulfate inhalation powder) ProAir HFA (albuterol sulfate) (Brand Name) ProAir Respiclick (albuterol sulfate) Proventil HFA (albuterol sulfate) (Brand Name) | Ventolin HFA (albuterol sulfate) (Brand Name) Albuterol HFA (generic ProAir HFA) Albuterol HFA (generic Proventil HFA) |
| Levalbuterol HFA (authorized generic Xopenex HFA) Xopenex HFA (levalbuterol) | Ventolin HFA (albuterol sulfate) (Brand Name) Albuterol HFA (generic ProAir HFA) Albuterol HFA (generic Proventil HFA) |
| Bevespi Aerosphere (glycopyrrolate/formoterol fumarate) Duaklir Pressair (aclidinium bromide/formoterol fumarate) Utibron Neohaler (indacaterol/glycopyrrolate) | Anoro Ellipta (umeclidinium/vilanterol) Stiolto Respimat (tiotropium bromide/olodaterol hydrochloride) |
| Alvesco (ciclesonide) Airduo Digihaler (fluticasone propionate/salmeterol) Airduo Respiclick (fluticasone propionate/salmeterol) ArmonAir Digihaler (fluticasone propionate) Flovent HFA / Flovent Diskus (fluticasone propionate) fluticasone propionate Diskus (authorized generic Flovent Diskus) Fluticasone furoate/vilanterol (authorized generic Breo Ellipta) Fluticasone propionate HFA (authorized generic Flovent HFA) Fluticasone propionate/salmeterol (authorized generic Airduo) Fluticasone propionate/salmeterol HFA (authorized generic Advair HFA) Pulmicort Flexhaler authorized generic (budesonide) | Advair HFA / Advair Diskus (fluticasone propionate/salmeterol) Airsupra (albuterol/budesonide)Arnuity Ellipta (fluticasone fuoate) Asmanex HFA/ Asmanex Twisthaler (mometasone furoate) Breo Ellipta (fluticasone furoate/vilanterol) Breyna (generic Symbicort) Budesonide/formoterol fumarate (generic Symbicort) Fluticasone propionate/salmeterol HFA (generic Advair HFA) Qvar RediHaler (beclomethasone dipropionate) Symbicort (budesonide/formoterol fumarate) |
Criteria for Approval of Restricted Product(s)
- The request is for coverage of SymlinPen; AND
- The patient is currently taking mealtime insulin; AND
- The patient cannot safely increase (optimize) their meal time insulin; OR
- The request is for Bexagliflozn (authorized generic Brenzavvy), Brenzavvy, Dapagliflozin (authorized generic Farxiga), Dapagliflozin/Metformin (authorized generic Xigduo XR), Inpefa, Invokana, Invokamet, Invokamet XR, Segluromet or Steglatro; AND
- BOTH of the following:
- The patient has tried and failed ONE of the following agents containing dapagliflozin: Farxiga, Xigduo XR; OR
- The patient has a clinical contraindication/intolerance to dapagliflozin; AND
- The patient has tried and failed ONE of the following agents containing empagliflozin: Jardiance/Synjardy/Synjardy XR, Glyxambi, Trijardy XR; OR
- The patient has a clinical contraindication/intolerance to empagliflozin; OR
- The patient has tried and failed ONE of the following agents containing dapagliflozin: Farxiga, Xigduo XR; OR
- BOTH of the following:
- The request is for Qtern or Steglujan; AND
- The patient has tried and failed ONE of the following: Glyxambi or Trijardy XR; OR
- The patient has a clinical contraindication/intolerance to ALL of the following: Glyxambi and Trijardy XR; OR
- The request is for Glargin yfgn (unbranded Semglee biosimilar), Insulin Glargine (unbranded Lantus biosimilar), or Rezvoglar (insulin glargine-aglr); AND
- The patient had a documented life-threatening side effect that required medical intervention to the Brand Semglee (insulin glargine-yfgn) or Brand Lantus (insulin glargine) interchangeable biosimilar product that is not anticipated with the requested product; AND
- The prescriber completed and submitted an FDA MedWatch Adverse Event Reporting Form (The prescriber must provide a copy of the completed MedWatch form. Authorization will not be considered unless the form is completed and submitted to the FDA); OR
- The patient had a documented life-threatening side effect that required medical intervention to the Brand Semglee (insulin glargine-yfgn) or Brand Lantus (insulin glargine) interchangeable biosimilar product that is not anticipated with the requested product; AND
- The request is for Insulin Degludec (unbranded Tresiba biosimilar) AND
- The patient had a documented life-threatening side effect that required medical intervention to the Brand Tresiba (insulin degludec) interchangeable biosimilar product that is not anticipated with the requested product; AND
- The prescriber completed and submitted an FDA MedWatch Adverse Event Reporting Form (The prescriber must provide a copy of the completed MedWatch form. Authorization will not be considered unless the form is completed and submitted to the FDA); OR
- The patient had a documented life-threatening side effect that required medical intervention to the Brand Tresiba (insulin degludec) interchangeable biosimilar product that is not anticipated with the requested product; AND
- The request is for Insulin Glargine (unbranded Toujeo biosimilar) AND
- The patient had a documented life-threatening side effect that required medical intervention to the Brand Toujeo (insulin glargine) interchangeable biosimilar product that is not anticipated with the requested product; AND
- The prescriber completed and submitted an FDA MedWatch Adverse Event Reporting Form (The prescriber must provide a copy of the completed MedWatch form. Authorization will not be considered unless the form is completed and submitted to the FDA); OR
- The patient had a documented life-threatening side effect that required medical intervention to the Brand Toujeo (insulin glargine) interchangeable biosimilar product that is not anticipated with the requested product; AND
- The request is for coverage of Proventil HFA® , ProAir HFA® , Albuterol HFA (authorized generic Ventolin HFA); AND
- The patient had a sub-therapeutic or intolerant response (therapeutic failure) to an inactive ingredient of an unrestricted/alternative product that is not present in Proventil HFA®, ProAir HFA®, Albuterol HFA (authorized generic Ventolin HFA); OR
- The patient has a documented intolerance to an inactive ingredient of the unrestricted/alternative product that is not found in Proventil HFA®, ProAir HFA®, Albuterol HFA (authorized generic Ventolin HFA); OR
- The prescriber provides a written, clinical, explanation for the medical necessity Proventil HFA®, ProAir HFA®, Albuterol HFA (authorized generic Ventolin HFA) over the unrestricted/alternative product; OR
- The request is for coverage of any other restricted medication; AND
- The patient has had a trial and failure of TWO therapeutically equivalent unrestricted medications, such as the alternatives listed in the chart above; OR
- The patient has a clinical contraindication/ intolerance to ALL of the unrestricted medications that have not been tried.
Duration of Approval: 365 days (1 year)
Quantity Limitations
Quantity limitations apply to brand and associated generic products*.
| Medication | Quantity per Day (unless specified) |
|---|---|
| BASAGLAR KWIKPEN – insulin glargine soln pen-injector 100 unit/ml | 100 mL every 30 days |
| BASAGLAR TEMPO PEN – insulin glargine pen-injector with transmitter port 100 unit/ml | 100 mL every 30 days |
| BRENZAVVY – bexagliflozn, bexagliflozin tab 20 mg | 1 tablet |
| FARXIGA – dapagliflozin 5 mg | 1 tablet |
| FARXIGA – dapagliflozin 10 mg | 1 tablet |
| GLARGIN YFGN – insulin glargine-yfgn inj 100 unit/ml | 100 mL every 30 days |
| GLARGIN YFGN – insulin glargine-yfgn soln pen-injector 100 unit/ml | 100 mL every 30 days |
| INPEFA – sotagliflozin tab 200 mg | 1 tablet |
| INPEFA – sotagliflozin tab 400 mg | 1 tablet |
| INSULIN DEGLUDEC – insulin degludec inj 100 unit/ml | 100 mL every 30 days |
| INSULIN DEGLUDEC – insulin degludec soln pen-injector 100 unit/ml | 100 mL every 30 days |
| INSULIN DEGLUDEC – insulin degludec soln pen-injector 200 unit/ml | 100 mL every 30 days |
| INSULIN GLARGINE – insulin glargine inj 100 unit/ml | 100 mL every 30 days |
| INSULIN GLARGINE – insulin glargine soln pen-injector 100 unit/ml | 100 mL every 30 days |
| INVOKAMET – canagliflozin-metformin hcl tab 150-1000 mg | 2 tablets |
| INVOKAMET – canagliflozin-metformin hcl tab 150-500 mg | 2 tablets |
| INVOKAMET – canagliflozin-metformin hcl tab 50-1000 mg | 2 tablets |
| INVOKAMET – canagliflozin-metformin hcl tab 50-500 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 150-1000 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 150-500 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 50-1000 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 50-500 mg | 2 tablets |
| INVOKANA – canagliflozin tab 100 mg | 1 tablet |
| INVOKANA – canagliflozin tab 300 mg | 1 tablet |
| JENTADUETO – linagliptin-metformin hcl tab 2.5-1000 mg | 2 tablets |
| JENTADUETO – linagliptin-metformin hcl tab 2.5-500 mg | 2 tablets |
| JENTADUETO – linagliptin-metformin hcl tab 2.5-850 mg | 2 tablets |
| JENTADUETO XR – linagliptin-metformin hcl tab er 24hr 2.5-1000 mg | 2 tablets |
| JENTADUETO XR – linagliptin-metformin hcl tab er 24hr 5-1000 mg | 1 tablet |
| KAZANO – alogliptin-metformin hcl tab 12.5-1000 mg | 2 tablets |
| KAZANO – alogliptin-metformin hcl tab 12.5-500 mg | 2 tablets |
| KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 2.5-1000 mg | 2 tablets |
| KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 5-1000 mg | 1 tablet |
| KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 5-500 mg | 1 tablet |
| LANTUS – insulin glargine inj 100 unit/ml | 100 mL every 30 days |
| LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml | 100 mL every 30 days |
| NESINA – alogliptin benzoate tab 12.5 mg | 1 tablet |
| NESINA – alogliptin benzoate tab 25 mg | 1 tablet |
| NESINA – alogliptin benzoate tab 6.25 mg | 1 tablet |
| ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv) | 1 tablet |
| ONGLYZA – saxagliptin hcl tab 5 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 12.5-15 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 12.5-30 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 12.5-45 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 25-15 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 25-30 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 25-45 mg | 1 tablet |
| QTERN – dapagliflozin-saxagliptin tab 10-5 mg | 1 tablet |
| QTERN – dapagliflozin-saxagliptin tab 5-5 mg | 1 tablet |
| REZVOGLAR KWIKPEN – insulin glargine-aglr soln pen-injector 100 unit/ml | 100 mL every 30 days |
| SEGLUROMET – ertugliflozin-metformin hcl tab 2.5-1000 mg | 2 tablets |
| SEGLUROMET – ertugliflozin-metformin hcl tab 2.5-500 mg | 4 tablets |
| SEGLUROMET – ertugliflozin-metformin hcl tab 7.5-1000 mg | 2 tablets |
| SEGLUROMET – ertugliflozin-metformin hcl tab 7.5-500 mg | 2 tablets |
| STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg | 1 tablet |
| STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg | 2 tablets |
| STEGLUJAN – ertugliflozin-sitagliptin tab 15-100 mg | 1 tablet |
| STEGLUJAN – ertugliflozin-sitagliptin tab 5-100 mg | 1 tablet |
| TRADJENTA – linagliptin tab 5 mg | 1 tablet |
| XIGDUO XR – dapagliflozin-metformin 5-1000 mg | 2 tablets |
| XIGDUO XR – dapagliflozin-metformin 10-1000 mg | 1 tablet |
| ZITUVIMET – sitagliptin-metformin hcl tab 50-500mg | 2 tablets |
| ZITUVIMET – sitagliptin-metformin hcl tab 50-1000mg | 2 tablets |
| ZITUVIMET XR – sitagliptin-metformin hcl er tab 50-500mg | 1 tablet |
| ZITUVIMET XR – sitagliptin-metformin hcl er tab 50-1000mg | 2 tablets |
| ZITUVIMET XR – sitagliptin-metformin hcl er tab 100-1000mg | 1 tablet |
| ZITUVIO - sitagliptin tab 25 mg | 1 tablet |
| ZITUVIO – sitagliptin tab 50 mg | 1 tablet |
| ZITUVIO – sitagliptin tab 100 mg | 1 tablet |
| ADVAIR DISKUS – fluticasone/salmeterol 100 mcg/50 mcg, 250 mcg/50 mcg, 500 mcg/50 mcg per inhalation (inhalation device, 60 blisters) | 60 blisters per 30 days |
| ADVAIR HFA – fluticasone/ salmeterol 45 mcg/21 mcg, 115 mcg/21 mcg, 230 mcg/21 mcg (12 gm, 120 actuations) | 1 canister per 30 days |
| AIRDUO DIGIHALER – fluticasone/salmeterol 55 mcg/14 mcg, 113 mcg/14 mcg, 232 mcg/14 mcg (0.45 gm, 60 actuations) | 1 inhaler per 30 days |
| AIRDUO RESPICLICK – fluticasone/salmeterol 55 mcg/14 mcg, 113 mcg/14 mcg, 232 mcg/14 mcg (0.45 gm, 60 actuations) | 1 inhaler per 30 days |
| AIRSUPRA – albuterol/budesonide 90 mcg/80mcg (10.7 gm, 120 actuations) | 3 inhalers per 30 days |
| ALVESCO – ciclesonide 80 mcg/actuation (6.1 gm, 60 actuations) | 1 canister per 30 days |
| ALVESCO – ciclesonide 160 mcg/actuation (6.1 gm, 60 actuations) | 2 canisters per 30 days |
| ANORO ELLIPTA – umeclidinium/vilanterol 62.5 mcg/25 mcg (60 blisters, 30 actuations) | 1 inhaler per 30 days |
| ARMONAIR DIGIHALER – fluticasone 55 mcg/actuation, 113 mcg/actuation, 232 mcg/actuation (0.9 g, 60 actuations) | 1 inhaler per 30 days |
| ASMANEX HFA – mometasone 50 mcg/actuation, 100 mcg/actuation, 200 mcg/actuation (13 gm, 120 actuations) | 1 canister per 30 days |
| ASMANEX TWISTHALER – mometasone 110 mcg/actuation (30 actuations), 220 mcg/actuation (30, 60, 120 actuations) | 1 canister per 30 days |
| BEVESPI AEROSPHERE – glycopyrrolate/formoterol 9 mcg/4.8 mcg (120 inhalation canister) | 1 canister per 30 days |
| BREO ELLIPTA – fluticasone furoate/vilanterol 100 mcg/25 mcg (60 blisters, 30 actuations) | 60 blisters per 30 days |
| BREO ELLIPTA – fluticasone furoate/vilanterol 200 mcg/25 mcg (60 blisters, 30 actuations) | 60 blisters per 30 days |
| DUAKLIR PRESSAIR – aclidinium bromide/formoterol fumarate 400 mcg/12 mcg (60 actuations) | 1 inhaler per 30 days |
| FLOVENT DISKUS – fluticasone 50 mcg/inhalation, 100 mcg/inhalation (60 blisters/carton) | 60 blisters per 30 days |
| FLOVENT DISKUS – fluticasone 250 mcg/inhalation (60 blisters/carton) | 240 blisters per 30 days |
| FLOVENT HFA – fluticasone 44 mcg/actuation, 110 mcg/actuation (10.6 gm, 120 actuations) | 1 canister per 30 days |
| FLOVENT HFA – fluticasone 220 mcg/actuation (12 gm, 120 actuations) | 2 canisters per 30 days |
| INCRUSE ELLIPTA – umeclidinium 62.5 mcg/blister | 30 blisters per 30 days |
| PROAIR DIGIHALER – albuterol sulfate 90 mcg/actuation (200 actuations) | 2 inhalers per 30 days |
| PROAIR HFA – albuterol sulfate HFA 90 mcg/actuation (8.5 gm, 200 actuations) | 2 canisters per 30 days |
| PROAIR RESPICLICK – albuterol sulfate 90 mcg/actuation (200 actuations) | 2 inhalers per 30 days |
| PROVENTIL HFA – albuterol sulfate 90 mcg/actuation (6.7 gm, 200 actuations) | 2 canisters per 30 days |
| PULMICORT FLEXHALER – budesonide 90 mcg/actuation (60 actuations) | 1 canister per 30 days |
| PULMICORT FLEXHALER – budesonide 180 mcg/actuation (120 actuations) | 2 canisters per 30 days |
| QVAR REDIHALER 40 mcg/actuation – (10.6 gm, 120 actuations) | 1 canister per 30 days |
| QVAR REDIHALER 80 mcg/actuation – (10.6 gm, 120 actuations) | 2 canisters per 30 days |
| SEREVENT DISKUS – salmeterol 50 mcg/inhalation (disposable inhalation device and 60 blisters) | 60 blisters per 30 days |
| SPIRIVA HANDIHALER – tiotropium 18 mcg/inhalation (carton of 5, 30, or 90 capsules) | 30 capsules per 30 days |
| SPIRIVA RESPIMAT – tiotropium 1.25 mcg/actuation, 2.5 mcg/actuation (4 g cartridge) | 1 cartridge per 30 days |
| STIOLTO RESPIMAT – tiotropium/olodaterol 2.5 mcg/2.5 mcg (4 grams, 60 actuations) | 1 cartridge per 30 days |
| SYMBICORT – budesonide/formoterol, Breyna 80 mcg/4.5 mcg, 160 mcg/4.5 mcg (10.2 gm, 120 actuations) | 3 canisters per 30 days |
| TUDORZA PRESSAIR – aclidinium bromide 400 mcg/actuation (1 canister, 60 actuations) | 1 canister per 30 days |
| UTIBRON NEOHALER – indacaterol/glycopyrrolate 27.5 mcg/15.6 mg/inhalation (Box of 60 inhalation capsules) | 60 capsules per 30 days |
| VENTOLIN HFA – albuterol sulfate 90 mcg/actuation (8 gm, 60 actuations) | 2 canisters per 30 days |
| VENTOLIN HFA – albuterol sulfate HFA 90 mcg/actuation (18 gm, 200 actuations) | 2 canisters per 30 days |
| XOPENEX HFA – levalbuterol HFA 45 mcg/actuation (15 gm, 200 actuations) | 2 canisters per 30 days |
Quantity Limit Exception Criteria
- The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND
- The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND
- The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR
- If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).
Duration of Approval: 365 days (1 year)
References
All information referenced is from FDA package insert unless otherwise noted below.
Policy Implementation/Update Information
Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.
March 2025: Criteria update: Removed Lantus from restricted products. Quantity limit still applies.
February 2025: Criteria update: Removed Airsupra from restricted products. Quantity limit still applies.
January 2025: Criteria update: Removed Levemir from list of Unrestricted Alternatives.
October 2024: Criteria update: Added new to market Zituvimet and Zituvimet XR.
July 2024: Criteria update: Added new to market sitagliptin-metformin
April 2024: Criteria update: Added new to market sitagliptin (authorized generic Zituvio)
January 2024: Criteria change: Added criteria point specific to Airsupra
January 2024: Criteria update: Added new to market insulin glargine (unbranded Toujeo biosimilar), dapagliflozin (authorized generic Farxiga), and dapagliflozin-metformin (authorized generic Xigduo XR
January 2024: Criteria update: Added new to market Zituvio to policy
January 2024: Criteria update: Flovent Diskus and Flovent HFA added to restricted products.
November 2023: Criteria update: Added Bexagliflozn (authorized generic Brenzavvy) and Inpefa 400mg to policy.
November 2023: Criteria update: Added fluticasone propionate Diskus (authorized generic Flovent Diskus) to policy.
November 2023: Criteria update: Updated insulin glargine-yfgn (unbranded Semglee biosimilar)’s product name to Glargin yfgn.
November 2023: Criteria update: Added authorized generic Pulmicort Flexhaler to policy.
September 2023: Criteria update: Added new to market Airsupra to policy.
September 2023: Criteria change: Combined Diabetes Value and Respiratory Value policies. Removed restriction from Beconase AQ, Omnaris and Qnasl. Removed Armonair Respiclick from policy (obsolete).
August 2023: Criteria update: Added new to market saxagliptin/metformin (generic Kombiglyze XR) to policy.
August 2023: Criteria update: Added new to market saxagliptin (generic Onglyza) to policy. Added budesonide/formoterol fumarate (generic Symbicort) and Breyna (generic Symbicort) to preferred products. Removed the authorized generic budesonide/formoterol from the policy.
August 2023: Criteria update: Added new to market Brenzavvy to policy.
June 2023: Criteria update: Added new to market Inpefa to policy.
March 2023: Criteria update: Added new to market Rezvoglar, an interchangeable biosimilar to Lantus, to policy. Added fluticasone/salmeterol HFA (authorized generic Advair HFA) to the policy.
December 2022: Criteria change: Added new to market Basaglar Tempo Pen to policy. Increased Symbicort QL to 3 canisters per 30 days.
September 2022: Criteria update: Added new to market Insulin Degludec (unbranded Tresiba biosimilar) to policy. Removed Seebri Neohaler and Aerospan from policy (obsolete products). Removed Dymista and generic Dymista from restriction.
June 2022: Criteria update: Added fluticasone propionate HFA (authorized generic Flovent HFA) and fluticasone furoate/vilanterol (authorized generic Breo Ellipta) to the policy.
May 2022: Criteria update: Added Insulin Glargine (unbranded Lantus biosimilar) to policy.
April 2022: Criteria update: Lantus added to restricted products. Semglee biosimilar added to suggested alternatives. QL added to Lantus, Invokana, Invokamet, Jentadueto, Jentadueto XR, Kazano, Kombligyze XR, Nesina, Onglyza, Oseni, Qtern, Segluromet, Steglatro, Steglujan and Tradjenta.
October 2021: Criteria update: Added new to market Insulin Glargine-yfgn, biosimilar to Lantus to policy.
October 2021: Criteria update: Added Segluromet, Seglatro and Qtern to policy. Invokana, Invokamet, Invokamet XR, Segluromet, Steglatro, Qtern,Steglujan given t/f criteria.
July 2021: Criteria update: Added Invokana, Invokamet, Invokamet XR to restricted products section. Duration of approval decreased to 365 days. Removed Peforomist from policy.
January 2021: Criteria update: Added Onglyza and Kombiglyze to restricted products section. Removed restriction on Trijardy XR.
*Additional historical revisions available upon request from Corporate Pharmacy
Disclosures:
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective owners.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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