Physicians/Specialists
Facilities/Hospitals
Pharmacy
Publication Date: 
2021-02-15

Effective April 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

  • Oxycontin

Updated Quantity Limits on Oxycontin 60mg and 80mg from 4 tablets to 2 tablets per day.  This aligns with other Oxycontin strengths.

  • Carafate Suspension
  • Sucralfate Suspension
  • Nitrofurantoin Suspension
  • Furadantin Suspension

These drugs will require Prior Authorization (only for members greater than 11 years old)

  • Sorilux
  • Calcipotriene 0.005% foam (generic Sorilux)
  • Procysbi

These drugs will require Prior Authorization & Step Therapy

  • Keveyis
  • Copaxone
  • Northera

These drugs will require Prior Authorization, Step Therapy, and Quantity Limits

  • Oxervate

This drug will require Prior Authorization & Quantity Limits

  • Sucraid

This drug will require Prior Authorization & Quantity Limits

  • Thiola
  • Thiola EC
  • Syprine
  • Trientine
  • Clovique
  • Depen

These drugs will require Prior Authorization & Step Therapy

  • Austedo
  • Xenazine
  • Tetrabenazine

These drugs will require Quantity Limits (they have and will continue to require PA)