Publication Date: 

Effective October 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
Creon, Zenpep  These medications will require Prior Authorization on Enhanced and Essential formularies. 
Cromolyn sodium nebulizer  This medication will require Quantity Limits. 
Exjade, Jadenu

These medications will require Prior Authorization and Quantity Limits. 


This medication will require Prior Authorization, Step Therapy and Quantity Limits. 

Relafen DS This medication will require Prior Authorization. 
Riastep, Fibryga 

These medications will require Prior Authorization and Quantity Limits. 

Sivextro This medication will require Quantity Limits. 
Xifaxan, Viberzi and Lotronex 

These medications will require Prior Authorization and Quantity Limits on the Essential formulary. 

Updated Requirements

Impacted Medications Requirement
Zyclara (imiquimod) 3.75% 

The requirements of Prior Authorization, Step Therapy and Quantity Limits already on Enhanced and Essential will be added to the Net Results formulary. 


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