FORMULARY CHANGES
Essential 6 Tier (Essential Q) formulary removals
Effective April 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.
Blue Cross NC is making these changes for a number of reasons, including:
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).
NEW REQUIREMENTS
NEW REQUIREMENTS
FORMULARY CHANGES
Essential 6 Tier (Essential Q) formulary removals
Medication | Suggested Formulary Alternative |
|---|---|
ALPRAZOLAM 0.5MG ODT | ALPRAZOLAM 0.5MG TABLET |
CALQUENCE CAP 100MG | CALQUENCE TAB 100MG |
DANTROLENE CAPS | BACLOFEN TABS |
GILENYA CAP 0.5MG | FINGOLIMOD CAP 0.5MG (GENERIC GILENYA) |
OXYCODONE 5MG CAPS | OXYCODONE 5MG TABS |
OXYMORPHONE ER TABLETS | MORPHINE SULFATE TAB ER, MORPHINE SULFATE CAP ER, XTAMPZA ER |
SUMATRIPTAN 4MG/0.5ML CARTRIDGE | SUMATRIPTAN INJ 4MG/0.5 SOLUTION AUTO-INJECTOR |
SUMATRIPTAN 6MG/0.5ML CARTRIDGE | SUMATRIPTAN INJ 6MG/0.5 SOLUTION AUTO-INJECTOR |
TRETINOIN 0.025% GEL | TRETINOIN CREAM 0.025% |
ZOLMITRIPTAN 2.5MG ODT | ZOLMITRIPTAN TAB 2.5 MG |
Essential 5 Tier (Essential C) formulary removals
Medication | Suggested Formulary Alternative |
|---|---|
ALPRAZOLAM 0.5MG ODT | ALPRAZOLAM 0.5MG TABLET |
CALQUENCE CAP 100MG | CALQUENCE TAB 100MG |
DANTROLENE CAPS | BACLOFEN TABS |
ELETRIPTAN 20MG, 40MG TABS | NARATRIPTAN TABS, RIZATRIPTAN TABS, SUMATRIPTAN TABS, ZOLMITRIPTAN TABS |
GILENYA CAP 0.5MG | FINGOLIMOD CAP 0.5MG (GENERIC GILENYA) |
OXYCODONE 5MG CAPS | OXYCODONE 5MG TABS |
OXYMORPHONE ER TABLETS | MORPHINE SULFATE TAB ER, MORPHINE SULFATE CAP ER, XTAMPZA ER |
SUMATRIPTAN 4MG/0.5ML CARTRIDGE | SUMATRIPTAN INJ 4MG/0.5 SOLUTION AUTO-INJECTOR |
SUMATRIPTAN 6MG/0.5ML CARTRIDGE | SUMATRIPTAN INJ 6MG/0.5 SOLUTION AUTO-INJECTOR |
TRETINOIN 0.025% GEL | TRETINOIN CREAM 0.025% |
ZOLMITRIPTAN 2.5MG ODT | ZOLMITRIPTAN TAB 2.5 MG |
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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