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Pharmacy Program Utilization Management Updates Effective July 1, 2022
April 29, 2022
Pharmacy

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 July 1, 2022.  

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 MEDICATIONS REQUIREMENT 
Amoxapine, Celexa, Cymbalta, Drizalma, Effexor, Effexor XR, Emsam, Fetzima, Khedelza, Lexapro, Marplan, Nortriptyline Solution, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Remeron, Remeron SolTab, Surmontil, Trintellix, Viibryd, Wellbutrin, Wellbutrin SR, Zoloft These medications and their generics (if applicable) will require Quantity Limits on all formularies. 
Restasis, Xiidra, Cequa These medications and their generics (if applicable) will require Quantity Limits on all formularies. 

NOTE: These limitations, like most quantity limitations, are based on the standard dosing of the FDA approved indications. 

Dose consolidation example: A patient receiving two 10mg tablets of paroxetine to achieve a single 20mg should change to a 20mg tablet to avoid exceeding a quantity limit of one 10mg tablet daily 

Max dose example: A patient is taking two 40 mg tablets of paroxetine. There is not an 80mg tablet and the standard dosing for paroxetine does not exceed 60mg. A quantity exception with clinical rationale would be needed for continued coverage. 

Titration example: Quantity limit exceptions can be approved for a period of 90 days at a time when an individual requires “in between” doses for the sake of titration. 

Updated Requirements 
IMPACTED MEDICATIONS REQUIREMENT 
Zenzedi 7.5mg tablets Quantity Limit reduced from 8 tablets per day to 3 tablets per day on all formularies. 
Korlym Quantity Limit reduced from 4 tablets per day to 3 tablets per day on all formularies unless documented weight above 45 kg. 
Scemblix This medication will require Step Therapy on all formularies for positive T3151 mutation. Iclusig will be preferred for positive T3151 mutation. Quantity Limit reduced from 10 tablets per day to 2 tablets per day on all formularies unless documented positive T3151 mutation. 

Formulary Changes
IMPACTED MEDICATIONS CHANGE TO FORMULARY 
Tyblume, Depo-SubQ Provera 104, VCG Vaginal Contraceptive Gel These medications will be removed from the Essential Formulary. 
Selzentry, Samsca 15mg, Cystadane powder, Vimpat tablets, Restasis Multidose 0.5% emulsion, Revlimid 5mg, 10mg, 15mg, 25mg K-Phos tablets These medications will be removed from the Essential Formulary due to the release of a generic formulation. These generic products are available on 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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