Publication Date: 

We want to inform you of changes to pharmacy utilization management requirements effective July 1, 2017. Below is a summary of the changes. More details can be found online.

These requirements will apply to all commercial members with pharmacy benefit coverage through Blue Cross and Blue Shield of North Carolina (Blue Cross NC). The changes noted will not apply to State Health Plan, Federal Employee Program, Medicare Part D members, or for any ASO employer groups that carve out their pharmacy benefits to another pharmacy benefits manager.

Pharmacy Utilization Management Changes

The following requirements apply to medications which are on a Blue Cross NC formulary. If a medication listed below is not on one of the Blue Cross NC formularies, the criteria referenced below will need to be met, as well as possible other requirements. Nonformulary requirements will be noted in the drug specific criteria found online.

Xifaxan - prior approval and a quantity limit will apply to all patients using this medication.

Topical Steroids (brand and generic formulations) - step therapy / restricted access will apply to all patients using the following medications: Apexicon E 0.05% cream, Capex Shampoo 0.01%, Clobex 0.05% lotion and spray, Clodern 0.1% cream, Cordran 0.05% cream, ointment, lotion, Cordran tape, Cutivate 0.05% lotion, Desonate Gel 0.05%, Desowen Lotion 0.05%, Desoximetasone 0.05% cream and ointment, Diflorasone 0.05% cream and ointment, Halog 0.1% cream and ointment, Kenalog spray, Locoid Lipo Cream 0.01%, Micort-HC 2.5% cream, Olux / Olux-E 0.05% foam, Pandel 0.1% cream, Psorcon 0.05% cream, Sernivo spray, Temovate 0.05% cream and gel, Topicort 0.05% cream and ointment, Topicort 0.25% ointment, Topicort 0.25% spray, Trianex 0.05% ointment, Triderm 0.1% cream, Vannos 0.1% cream, Verdeso 0.05%

Please note: Temovate E cream and its generic, clobatesol emollient cream, are preferred medications and will NOT have step therapy / restricted access requirements.

Pharmacy Benefit Changes

The following medications will no longer be covered:

  • Differin gel 0.1% - available over-the-counter (OTC)
  • Schedule 5 OTC cough and cold products
  • Injectables covered under the medical benefit - including but not limited to Adagen, Faslodex, Fibrin, Iprivask, Thrombin and Vidaza

If you have any questions, please contact the Provider Blue LineSM at 1-800-214-4844.