Blue Cross NC pharmacy UM 60-day network notice

Effective October 1, 2023, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have changes to our pharmacy utilization management (UM) requirements. Below is a high-level summary of the changes. More details can be found here.

New Requirements

• Chorionic Gonadotropin and Novarel – These medications will require Step Therapy on Enhanced formularies, Non-Formulary Exception on Essential formularies and Medical Necessity Prior Authorization on Net Results formulary. Ovidrel and Pregnyl will be preferred products on the Enhanced and Net Results Formularies. Pregnyl will be the preferred product on Essential formularies. This change will only impact members new to therapy.
• Spravato – This medication will require Quantity Limits within 8 packs per 28 days across all formularies.

Updated Requirements

• Dutasteride-tamsulosin capsule – This medication will require Medical Necessity Prior Authorization on the Net Results formulary.
• Uptravi – The Quantity Limit for this medication will be updated to limit quantities to 60 tablets per 30 days across all strengths. This update will apply to all formularies.
• Xyrem – This medication will require additional Step Therapy through Sodium Oxybate (Authorized Generic of Xyrem) for new utilizers across all formularies. This medication will require Medical Necessity Prior Authorization on the Net Results formulary.

Blue Cross NC is making these changes for a number of reasons, including: 

• Blue Cross NC is taking several steps to help control the prices of prescription drugs for our customers. Many of the changes we are making will help us continue to offer sustainable health plans for our customers over the long term. 

• Ongoing programs such as utilization management and formulary management help us provide our members with access to drugs that are safe, effective and as cost-efficient as possible. 

• Blue Cross NC is committed to helping our members get the most appropriate medications. We regularly review medical research and costs of medications. A team of doctors and pharmacists use this information to make sure Blue Cross NC covers the most effective medicines while keeping costs more affordable for everyone. 

We encourage our members to talk to their doctors and pharmacists, to determine if lower cost medications may meet their needs. Customers can find more information about prescription drug coverage and costs here. 

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). 

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