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May 2016
Blue Cross setting new quantity limits for Enbrel®, Humira®, Actemra® and Cimzia®
On June 1, 2016, Blue Cross Blue Shield of Michigan will implement new quantity limits for the following drugs:
Drug |
Strength |
Quantity covered for 30 days |
Enbrel® |
25 mg multiple-use vial |
1 package (4 vials) |
25 mg/0.5 ml single-use prefilled syringe |
1 package (4 syringes) |
50 mg/ml single-use prefilled auto injector |
1 package (4 auto injectors) |
50 mg/ml single-use prefilled syringe |
1 package (4 syringes) |
Humira®
|
10 mg/0.2 ml single-use prefilled syringe |
1 package (2 syringes) |
20 mg/0.4 ml single-use prefilled syringe |
1 package (2 syringes) |
40 mg/0.8 ml single-use prefilled syringe |
2 packages (4 syringes) |
Humira® pen |
40 mg/0.8 ml single-use prefilled pen |
2 packages (4 pens) |
Humira® pen - pediatric
|
40 mg/0.8 ml single-use prefilled pen
(starter pack** with 3 pens) |
2 packages (6 pens) per 365 days |
40 mg/0.8 ml single-use prefilled pen
(starter pack** with 6 pens) |
2 packages (12 pens) per 365 days |
Humira® pen
- Crohn’s disease
- Ulcerative colitis
- Hidradenitis suppurativa
|
40 mg/0.8ml single-use prefilled pen
(starter pack**) |
2 packages (12 pens) per 365 days |
Humira® pen
|
40 mg/0.8 ml single-use prefilled pen
(starter pack**) |
2 packages (8 pens) per 365 days |
Actemra® |
162 mg/0.9ml single-use prefilled syringe |
4 packages (4 syringes) |
Cimzia® |
200 mg/ml single-use prefilled syringe |
1 package (2 syringes) |
Cimzia® |
200 mg/ml single-use prefilled syringe
(starter pack**) |
2 packages (12 syringes) per 365 days |
**Starter packs are limited to a maximum of two packages per year.
The quantity limits only affect our commercial (non-Medicare) members who have Blue Cross pharmacy benefits that include quantity limits. They don’t apply to MESSA members.
If necessary, you can request an override of the quantity limits for your patients. The request should include documentation stating that the amount prescribed is medically necessary. To get a form for a quantity limit override, log in as a provider at bcbsm.com or call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.
Our goal is to provide our members with safe, high-quality prescription drug therapies. Enbrel®, Humira®, Actemra® and Cimzia® are high-cost specialty medications. To help our members maintain lower premiums, we’re attempting to limit waste or overutilization of expensive medications. The quantity limits align with dosing guidelines approved by the U.S. Food and Drug Administration to minimize potentially unsafe drug use by our members.
We sent letters in April to notify members who may be affected by these quantity limit changes. The letters encourage members to discuss treatment options with their physicians.
If you have any questions about this program, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803. | 