Pharmacy Program Utilization Management Updates Effective April 1, 2022
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will apply the following new requirements to our pharmacy utilization management for the below listed drugs. These changes will be effective April 1, 2022.
Our utilization management requirements apply to all commercial members with pharmacy benefit coverage through Blue Cross NC. These changes will not apply to the following lines of business: 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
| IMPACTED MEDICATIONS | REQUIREMENT | |
|---|---|---|
| Lantus | This medication will require Step Therapy on all formularies. Brand Semglee (biosimilar) will be preferred. | |
| Carbaglu | This medication will require Prior Authorization on all formularies. | |
| Januvia, Janumet, Janumet XR, Jentadueto, Jentadueto XR, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Tradjenta | These medications and their generics (if applicable) will require Quantity Limits on all formularies. | |
| Farxiga, Glyxambi, Invokamet, Invokamet XR, Invokana, Jardiance, Qtern, Segluromet, Steglatro, Steglujan, Synjardy, Synjardy XR, Trijardy XR, Xigduo XR | These medications and their generics (if applicable) will require Quantity Limits on all formularies. | |
| Aptivus, Atripa, Biktarvy, Cimduo, Complera, Crixivan, Delstrigo, Descovy, Dovato, Edurant, Emtriva, Evotaz, Fuzeon, Genvoya, Intelence, Invirase, Isentress, Isentress HD, Juluca, Kaletra, Lexiva, Norvir, Odefsey, Pifeltro, Prezocobix, Presizta, Rescriptor, Reyataz, Rukobia, Selzentry, Stribild, Symfi, Symfi Lo, Symtuza, Tivicay, Tivicay PD, Triumeq, Truvada, Tybost, Videx, Videx EC, Viracept, Viramune, Viread, Retrovir | These medications and their generics (if applicable) will require Quantity Limits on all formularies. | |
| Kalydeco, Orkambi, Symdeko, Trikafta | These medications and their generics (if applicable) will require Quantity Limits on all formularies. | |
| Eliquis, Pradaxa, Savaysa, Xarelto | These medications and their generics (if applicable) will require Quantity Limits on all formularies. | |
| Cetrotide, Follistim AQ, Granirelix AC, Gonal-F, Menopur, Novarel, Ovidrel | These medications and their generics (if applicable) will require Quantity Limits on all formularies. | |
| Oxbryta | This medication will require Quantity Limits on all formularies. | |
| Advate, Adynovate, Afstyla, AlphaNine SD, Alprolix, Bebulin, BeneFIX, Eloctate, Esperoct, Helixate FS, Hemofil M, Idelvion, Ixinity, Jivi, Koāte/Koāte-DVI, Kogenate FS, Kovaltry, Mononine, NovoEight, Nuwiq, Profilnine, Rebinyn, Recombinate, Vonvendi, Wilate, Xyntha/Xyntha Solofuse– | These medications and their generics (if applicable) will require Quantity Limits on all formularies. |
If you have any questions, please call the Provider Blue Line℠ at 800-214-4844.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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