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90 Day Notice for Pharmacy Utilization Management Requirements April 01, 2021 Pharmacy

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.

 

NEW REQUIREMENTS
Impacted MedicationsRequirement
ActimmuneThis 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, WixkelaThese medication will require Quantity Limits.
ArcalystThis medication will require Prior Authorization and Quantity Limits.
Flunisolide Nasal SprayThis medication will require Step Therapy on the Essential formulary. The preferred products will be over-the-counter intranasal steroid products.
Invokana, Invokamet, Invokamet XRThese medications will require Step Therapy. The preferred products will be Farxiga, Jardiance, Trijardy and Xigduo XR.
Levocetirizine solution, Desloratadine ODT, Prevacid ODT, Phoslyra solutionhese 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 tabletsThis 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 tabletsThese 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 MedicationsRequirements 
Hetlioz tabletsThis medication will require Step Therapy and Quantity Limits. 
Nefazodone, Carisoprodol, Carisoprodol/ASA, ThioridazineThe requirements of Prior Authorization and Step Therapy already on Enhanced will be added to Essential and Net Results formularies. 
ProAir, Proventil, Ventolin, XopenexThe Quantity Limits of this medication will decrease from 6 inhalers per day to 2 inhalers per 30 days. 
Xtandi 40mg capsulesThe 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 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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