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Pharmacy Program Updates Effective October 1, 2021 July 26, 2021 Pharmacy

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. 

New Requirements
IMPACTED MEDICATIONSREQUIREMENT
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. 

Ferriprox

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

Relafen DSThis medication will require Prior Authorization. 
Riastep, Fibryga

These medications will require Prior Authorization and Quantity Limits. 

SivextroThis 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 MEDICATIONSREQUIREMENT
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 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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