Pharmacy Utilization Management Requirements Update Effective July 1, 2023

Effective July 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:

• 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 by accessing our "Find Care" tool.

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

Creon, Zenpep – These medications and their generics (if applicable) will require Quantity Limits within 10,000 units/kg/day in alignment with Pancreatic Enzymes Clinical Care Guidelines on Enhanced and Essential formularies.

Pancreaze, Pertzye, Viokace – These medications and their generics (if applicable) will require Quantity Limits within 10,000 units/kg/day in alignment with Pancreatic Enzymes Clinical Care Guidelines on across all formularies.

Calcitriol oral solution, colesevelam packet for suspension, Brand Dexilant, diltiazem coated beads ER tab 420mg, doxercalciferol capsule, isradipine capsule, nicardipine capsule, Nisoldipine ER, Nitromist, paricalcitol, sapropterin dihydrochloride (Javygtor) powder packet and tablet, telmisartan-hydrochlorothiazide tablet, Trandolapril/Verapamil ER, Brand Verapamil ER 100mg, 200mg, 300mg capsule, Brand Verapamil SR 360mg capsule –  These medications will require Medical Necessity Prior Authorization on the Net Results formulary.

Dexlansoprazole (generic Dexilant) – This medication will be excluded from coverage for Net Results Full members. Alternatives include OTC lansoprazole, OTC esomeprazole, OTC omeprazole, etc.

UPDATED REQUIREMENTS

Tarpeyo – Step therapy for this medication will be updated from current step through prednisone and methylprednisolone to require trial of glucocorticoid and generic budesonide for new utilizers across all formularies.

Ravicti – This medication will require additional step therapy through Pheburane and generic sodium phenylbutyrate tablet or powder for new utilizers across all formularies.

Humatrope, HumatroPEN, Nutropin, Nutropin AQ, Nutropin AQ Nuspin, Omnitrope, Saizen, Serostim, Skytrofa, Zomacton, Zorbitive – Continuation Criteria for these medications will be updated across all formularies to require step through Norditropin or Genotropin if not trialed on initial approval.

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