Pharmacy Program Utilization Management Updates Effective January 1, 2023

Effective January 1, 2023, 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

Carbatrol capsule, Digoxin solution, Dilantin chew/suspension/tablet, Lanoxin tablet, Lithobid tablet, Mysoline tablet, Neoral capsule/solution, Norpace capsule, Phenytek capsule, Prograf capsule, Rapamune tablet/solution, Sandimmune capsule, Tegretol tablet/solution, Tegretol-XR tablet, Zarontin capsul/solution, Zortress tablet – These Brand products with available generic alternatives will require Prior Authorization on the Essential formularies for members new to therapy. Members will be required to trial the generic product prior to the approval of the brand.

Dymista – This medication and its generic will require Step Therapy on the Essential formularies. The Step Therapy requirement is two over-the-counter intranasal steroid medications.

Updated Requirements

Mounjaro 2.5mg injection – Quantity Limit reduced from 8 injections per month to 4 injections per 180 days on all formularies. 

Rybelsus 3mg tablet – Quantity Limit reduced from 1 tablet per day to 30 tablets per 180 days on all formularies. 

Formulary Changes

Xiidra 5% Drops – This medication will be removed from all Essential formularies. Members with claims for Xiidra 5% drops in the last 120 days will automatically receive an authorization for Restasis 0.05% single dose vial effective 1/1/2023. 

Brand Vagifem – This medication will be removed from all Essential formularies and the generic version, estradiol 10mg tablet, will be added to formulary as the preferred product.  

Essential 6 Tier (Essential Q) formulary removals

• ARAKODA      TAB 100MG
  
• AMCINONIDE   LOT 0.1%
• IMBRUVICA 280MG TAB
• KRINTAFEL    TAB 150MG
• LAMICTAL XR  KIT
• NUVESSA      GEL 1.3%
• PRADAXA CAP 150MG
• SUPREP BOWEL SOL PREP KIT
• TAZORAC GEL 0.05%
• TAZORAC GEL 0.1%
• VAGIFEM
• VIIBRYD STARTER PACK
• XIIDRA       DRO 5%

Essential 5 Tier (Essential C) formulary removals

• ACYCLOVIR    OIN 5%
• ADAPAL/BEN P GEL 0.1-2.5%
• ALMOTRIP MAL TAB 12.5MG
• ALMOTRIP MAL TAB 6.25MG
• ALOCRIL      SOL 2%
• ALOMIDE      SOL 0.1% OP
• ALTABAX      OIN 1%
• AMCINONIDE   LOT 0.1%
• AMOXAPINE    TAB 100MG
• AMOXAPINE    TAB 150MG
• AMOXAPINE    TAB 25MG
• AMOXAPINE    TAB 50MG
• APADAZ       TAB 4.08-325
• APADAZ       TAB 6.12-325
• APADAZ       TAB 8.16-325
• ARAKODA      TAB 100MG
• BEPOTASTINE  DRO 1.5%
• BESIVANCE    SUS 0.6%
• BRINZOLAMIDE SUS 1%
• BUPRENORPHIN DIS 10MCG/HR
• BUPRENORPHIN DIS 15MCG/HR
• BUPRENORPHIN DIS 20MCG/HR
• BUPRENORPHIN DIS 5MCG/HR
• BUPRENORPHIN DIS 7.5/HR
• BUSPIRONE    TAB 7.5MG
• CALCIPOTRIEN OIN 0.005%
• CALCITRENE   OIN 0.005%
• CALCITRIOL   OIN 3MCG/GM
• CARISOPRODOL TAB 250MG
• CARISOPRODOL TAB 350MG
• CEFACLOR     SUS 125/5ML
• CEFACLOR     SUS 250/5ML
• CEFACLOR     SUS 375/5ML
• CEPHALEXIN   TAB 250MG
• CIMETIDINE   SOL 300/5ML
• CIMETIDINE   SOL 400MG
• CLOCORTOLONE CRE 0.1%
• CONSENSI     TAB 10-200MG
• CONSENSI     TAB 2.5-200
• CONSENSI     TAB 5-200MG
• DARIFENACIN  TAB 15MG
• DARIFENACIN  TAB 7.5MG
• DESLORATADIN TAB 2.5 ODT
• DESLORATADIN TAB 5MG ODT
• DEXILANT     CAP 30MG DR
• DEXILANT     CAP 60MG DR
• DIFLORASONE  CRE 0.05%
• DIFLUPREDNAT EMU 0.05%
• EPINASTINE   DRO 0.05%
• EPOGEN       INJ 10000/ML
• EPOGEN       INJ 2000/ML
• EPOGEN       INJ 20000/ML
• EPOGEN       INJ 3000/ML
• EPOGEN       INJ 4000/ML
• ERGOLOID MES TAB 1MG ORAL
• ERTACZO      CRE 2%
• ERY/BENZOYL  GEL 3-5%
• EVEKEO ODT   TAB 10MG
• EVEKEO ODT   TAB 5MG
• EXELDERM     SOL 1%
• FEBUXOSTAT   TAB 40MG
• FEBUXOSTAT   TAB 80MG
• FENOPROFEN   TAB 600MG
• FLUOXETINE   TAB 10MG
• FLUVASTATIN  CAP 20MG
• FLUVASTATIN  CAP 40MG
• FROVATRIPTAN TAB 2.5MG
• FULPHILA     INJ 6/0.6ML
• FUROSEMIDE   SOL 8MG/ML
• GRANIX       INJ 300/0.5
• GRANIX       INJ 300/1ML
• GRANIX       INJ 480/0.8
• GRANIX       INJ 480/1.6
• HALDOL DECAN INJ 100MG/ML
• HALDOL DECAN INJ 50MG/ML
• HALOG        OIN 0.1%
• HC BUTYRATE  CRE 0.1%
• HC BUTYRATE  SOL 0.1%
• HYDROCO/APAP TAB 10-300MG
• HYDROCO/APAP TAB 5-300MG
• HYDROCO/APAP TAB 7.5-300
• HYDROCODONE  TAB 100MG ER
• HYDROCODONE  TAB 120MG ER
• HYDROCODONE  TAB 20MG ER
• HYDROCODONE  TAB 30MG ER
• HYDROCODONE  TAB 40MG ER
• HYDROCODONE  TAB 60MG ER
• HYDROCODONE  TAB 80MG ER
• HYDROMORPHON TAB 12MG ER
• HYDROMORPHON TAB 16MG ER
• HYDROMORPHON TAB 32MG ER
• HYDROMORPHON TAB 8MG ER
• ILEVRO       DRO 0.3% OP
• IMBRUVICA 280MG TAB
• IMCIVREE     INJ 10MG/ML
• INFASURF     SUS 35MG/ML
• IRBESAR/HCTZ TAB 150-12.5
• IRBESAR/HCTZ TAB 300-12.5
• KADIAN       CAP 200MG ER
• KETOPROFEN   CAP 200MG ER
• KRINTAFEL    TAB 150MG
• LAMICTAL XR  KIT
• LANSOPR/AMOX MIS /CLARITH
• LANSOPRAZOLE TAB 15MG ODT
• LANSOPRAZOLE TAB 30MG
• LANSOPRAZOLE TAB 30MG ODT
• LASTACAFT    SOL 0.25%
• LEVOCETIRIZI SOL 2.5/5ML
• LEVORPHANOL  TAB 2MG
• LEVORPHANOL  TAB 3MG
• LUBIPROSTONE CAP 24MCG
• LUBIPROSTONE CAP 8MCG
• LUMIGAN      SOL 0.01%
• MAPROTILINE  TAB 25MG
• MAPROTILINE  TAB 50MG
• MAPROTILINE  TAB 75MG
• MECLOFEN SOD CAP 100MG
• MECLOFEN SOD CAP 50MG
• MEPROBAMATE  TAB 200MG
• MEPROBAMATE  TAB 400MG
• METAXALONE   TAB 400MG
• METAXALONE   TAB 800MG
• METHAMPHETAM TAB 5MG
• MORPHINE SUL CAP 40MG ER
• MOZOBIL      INJ
• NAFTIFINE    CRE HCL 1%
• NEBIVOLOL    TAB 10MG
• NEBIVOLOL    TAB 2.5MG
• NEBIVOLOL    TAB 20MG
• NEBIVOLOL    TAB 5MG
• NEFAZODONE   TAB 100MG
• NEFAZODONE   TAB 150MG
• NEFAZODONE   TAB 200MG
• NEFAZODONE   TAB 250MG
• NEFAZODONE   TAB 50MG
• NEULASTA     INJ 6MG/0.6M
• NEULASTA     KIT 6MG/0.6M
• NEUPOGEN     INJ 300/0.5
• NEUPOGEN     INJ 300MCG
• NEUPOGEN     INJ 480/0.8
• NEUPOGEN     INJ 480MCG
• NIZATIDINE   CAP 150MG
• NIZATIDINE   CAP 300MG
• NIZATIDINE   SOL 15MG/ML
• NUVESSA      GEL 1.3%
• NYSTAT/TRIAM CRE
• NYVEPRIA     INJ 6/0.6ML
• OLOPATADINE  SPR 0.6%
• OMEPRA/BICAR POW 20-1680
• OMEPRA/BICAR POW 40-1680
• ONGENTYS     CAP 25MG
• ONGENTYS     CAP 50MG
• OTOVEL       DRO
• OXICONAZOLE  CRE NITRATE
• PEG/NASUL/C/ SOL NACL/POT
• PHOSPHOLINE  SOL 0.125%OP
• PRADAXA CAP 150MG
• PREPIDIL     GEL 0.5MG/3G
• PRILOSEC     POW 10MG
• PRILOSEC     POW 2.5MG
• PROCRIT      INJ 10000/ML
• PROCRIT      INJ 2000/ML
• PROCRIT      INJ 20000/ML
• PROCRIT      INJ 3000/ML
• PROCRIT      INJ 4000/ML
• PROCRIT      INJ 40000/ML
• PROSTIN E2   SUP 20MG
• PSORCON      CRE 0.05%
• RABEPRAZOLE  TAB 20MG
• RAMELTEON    TAB 8MG
• RIBAVIRIN    INH 6GM
• SAVELLA      MIS TITR PAK
• SAVELLA      TAB 100MG
• SAVELLA      TAB 12.5MG
• SAVELLA      TAB 25MG
• SAVELLA      TAB 50MG
• SILODOSIN    CAP 4MG
• SILODOSIN    CAP 8MG
• SOLOSEC      GRA 2GM
• SUPREP BOWEL SOL PREP KIT
• TAZORAC GEL 0.05%
• TAZORAC GEL 0.1%
• TESTOSTERONE GEL 1%(50MG) PACKETS
• TESTOSTERONE GEL PUMP 1%
• THIORIDAZINE TAB 100MG
• THIORIDAZINE TAB 10MG
• THIORIDAZINE TAB 25MG
• THIORIDAZINE TAB 50MG
• TRAVOPROST   DRO 0.004%
• TRIAZOLAM    TAB 0.125MG
• TRIAZOLAM    TAB 0.25MG
• TUZISTRA XR  SUS
• VAGIFEM
• VANADOM      TAB 350MG
• VIIBRYD STARTER PACK
• XIIDRA       DRO 5%
• ZERVIATE     DRO 0.24%
• ZILEUTON ER  TAB 600MG
• ZIRGAN       GEL 0.15%
• ZUBSOLV      SUB 0.7-0.18
• ZUBSOLV      SUB 1.4-0.36
• ZUBSOLV      SUB 11.4-2.9
• ZUBSOLV      SUB 2.9-0.71
• ZUBSOLV      SUB 5.7-1.4
• ZUBSOLV      SUB 8.6-2.1

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