Blue Cross NC Pharmacy Utilization Management Requirements Update

Effective April 1, 2023, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have changes to our pharmacy utilization management (UM) requirements. Below is a high-level summary of the changes.

Blue Cross NC is making these changes for a number of reasons, including:  

• Blue Cross NC is taking several steps to help control the prices of prescription drugs for our customers. Many of the changes we are making will help us continue to offer sustainable health plans for our customers over the long term. 
• Ongoing programs such as utilization management and formulary management help us provide our members with access to drugs that are safe, effective and as cost-efficient as possible. 
• Blue Cross NC is committed to helping our members get the most appropriate medications. We regularly review medical research and costs of medications. A team of doctors and pharmacists use this information to make sure Blue Cross NC covers the most effective medicines while keeping costs more affordable for everyone. 
• We encourage our members to talk to their doctors and pharmacists, to determine if lower-cost medications may meet their needs. Members can find more information about prescription drug coverage and costs by using the Find Care tool.   

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). 

NEW REQUIREMENTS

• Renvela (sevelamer) powder – This medication and its generic will require Prior Authorization on all formularies for members > 11 years of age. Renvela (sevelamer) tablets are preferred. 
• Amitiza, Ibsrela, Linzess, Motegrity, Movantik, Relistor, Symproic, Trulance – These medications and their generics will require Quantity Limits on all formularies.  
• Nexletol, Nexlizet – These medications and their generics will require Quantity Limits on all formularies.  
• Clovique, Cuprimine, Depen, Penicillamine, Syprine, Thiola, Thiola EC, Tiopronin, Trientine – These medications will require Quantity Limits on all formularies. 

NEW REQUIREMENTS

• Noxafil (posaconazole) – For the treatment of oropharyngeal candidiasis, new utilizers will be required to have an inadequate response to or is unable to take itraconazole solution on all formularies.