Physicians/Specialists
Facilities/Hospitals
Pharmacy
Publication Date: 
2021-04-01

Effective July 1, 2021, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have changes to our pharmacy utilization management (UM) requirements.

Our UM requirements apply to all commercial members with pharmacy benefit coverage through Blue Cross NC. These changes do not affect State Health Plan, Federal Employee Program, Medicare Part D members, or any self-funded employer groups that carve out pharmacy benefits to another pharmacy benefits manager (PBM).

Below is a summary of the changes, and more details can be found here.

 

NEW REQUIREMENTS

Impacted Medications Requirement
Actimmune This medication will require Prior Authorization.
Advair, AirDuo, Alvesco, Anoro Ellipta, Arcapta Neohaler, ArmonAir, Arnuity Ellipta, Asmanex, Atrovent HFA, Bevespi Aerosphere, Breo Ellipta, Breztri, Combivent Respimat, Duklair Pressair, Dulera, Flovent, Incruse Ellipta, Pulmicort, QVAR, Seebri Neohaler, Serevent Diskus, Spiriva, Stiolto, Striverdi, Symbicort, Trelegy, Tudorza, Utibron, Wixkela These medication will require Quantity Limits.
Arcalyst This medication will require Prior Authorization and Quantity Limits.
Flunisolide Nasal Spray This medication will require Step Therapy on the Essential formulary. The preferred products will be over-the-counter intranasal steroid products.
Invokana, Invokamet, Invokamet XR These medications will require Step Therapy. The preferred products will be Farxiga, Jardiance, Trijardy and Xigduo XR.
Levocetirizine solution, Desloratadine ODT, Prevacid ODT, Phoslyra solution hese medications will require Prior Authorization. Prior Authorization will only apply for members > 11 years of age.
Lidocaine-Prilocaine 2.5-2.5% This medication will require Prior Authorization, Step Therapy and Quantity Limits.
Prolate tablets This medication will require Prior Authorization and Step Therapy. The preferred products will be oxycodone w/ acetaminophen 5-325mg, oxycodone w/ acetaminophen 7.5-325mg, or oxycodone w/ acetaminophen 10-325mg.
Protonix tablets, Aciphex tablets These medications will require Step Therapy. The preferred products will be over-the-counter proton pump inhibitors.
Truvada 200-300mg, Descovy

These medications will require Quantity Limits.

 

UPDATED REQUIREMENTS

Impacted Medications Requirements
Hetlioz tablets This medication will require Step Therapy and Quantity Limits.
Nefazodone, Carisoprodol, Carisoprodol/ASA, Thioridazine The requirements of Prior Authorization and Step Therapy already on Enhanced will be added to Essential and Net Results formularies.
ProAir, Proventil, Ventolin, Xopenex The Quantity Limits of this medication will decrease from 6 inhalers per day to 2 inhalers per 30 days.
Xtandi 40mg capsules The Quantity Limits of this medication will decrease from 4 capsules per day to 3 capsules per day.

 

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