Overview of Blue Cross NC’s commercial medical formulary guide

This provider news post aims to provide an overview of the Medical Management Formulary Drug Guide (PDF).

Medical Formulary Guide Summary

Per recent Prime Therapeutics® data, medical drug spending is the fastest-growing segment, representing 25% of total drug spending (1). The Blue Cross and Blue Shield of North Carolina (Blue Cross NC) Commercial Medical Formulary Guide offers a complete drug management plan. The guide aims to help providers and employer groups improve drug usage by identifying strategies under the medical drug benefit in critical therapeutic areas.

The strategies included are chosen based on their clinical effectiveness and cost-effectiveness. Our Pharmacy and Therapeutics (P&T) Committee has evaluated these strategies to improve the health outcomes of our members.

How does the guide work?

• The Commercial Medical Formulary Guide implements various approaches to ensure clinical appropriateness and manage medical expenses effectively. These include incorporating biosimilars, medical rebates, step therapy strategies, quantity limits, partnering with specialty-focused vendors, and providing low net cost savings.
• Providers can utilize the guide to understand the strategies better and access a comprehensive list of drugs covered under the medical benefit that utilize these approaches.
• Specific prior authorization policies for medications covered under the medical benefit can be found here.
• Updates to the guide are quarterly.

Member Experience

Member experience differs depending on the medical drug use and strategies to ensure appropriateness and cost-effectiveness for members and employers.

Sources

1. Prime Therapeutics® internal data