Update: Blue Cross NC Pharmacy UM 60-Day Network Notice

Update: This post is an update to the original 60-day Network Notice posted on November 1, 2023. This post now includes Essential Q and Essential QS formulary removals.

Effective January 1, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have changes to our pharmacy utilization management (UM) requirements.

Blue Cross NC is implementing 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 on our drug search page.

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 high-level summary of the changes. View our drug search page more details. 

NEW REQUIREMENTS

Flovent Diskus, Flovent HFA – These medications will require Step Therapy on the Enhanced formulary, non-formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Preferred products include Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler and Qvar Redihaler.

Tiotropium capsules (generic Spiriva Handihaler) – This medication will require Prior Authorization on the Enhanced formulary. Brand Spiriva Handihaler is preferred.

Ibrance – This medication will require Step Therapy on Enhanced and Net Results formularies and non-formulary review on the Essential formularies for new utilizers. Preferred products include Kisqali and Verzenio.

UPDATED REQUIREMENTS

Levocetirizine solution 2.5mg / 5ml – This medication will be a benefit exclusion for Fully Insured members on the Enhanced and Essential formularies due to the availability of an over-the-counter version of the product (OTC Xyzal Allergy 24Hr Childrens).

Victoza – This medication will require Step Therapy on the Enhanced formulary, Non-Formulary review on the Essential formularies, and Value Prior Authorization on the Net Results formulary. Preferred products include Ozempic, Trulicity, Mounjaro, and Bydureon.

Brand Advair Diskus – This medication will require non-formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Preferred products include Fluticasone propionate / salmeterol diskus and Wixela (generic Advair Diskus products).

Brand Vyvanse – This medication will require non-formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Lisdexamphetamine (generic Vyvanse) is preferred.

Brand Symbicort – This medication will require Value Prior Authorization on the Net Results Formulary. Preferred products include Budesonide-formoterol aerosol and Breyna (generic Symbicort products).

Brand Palynziq – This medication will require non-formulary review on the Essential formularies.  Sapropterin (generic Kuvan) is preferred.

Sodium Phenylbutyrate Tablets – This medication will require non-formulary review on the Essential formularies.  Sodium phenylbutyrate oral powder is preferred.

Epogen, Procrit – This medication will require non-formulary review on the Essential Q formulary.  Retacrit is preferred.

Granix – This medication will require non-formulary review on the Essential Q formulary. Nivestym and Zarxio are preferred.

Neulasta, Neupogen, Nyvepria – This medication will require non-formulary review on the Essential Q formulary.  Udenyco and Ziextenzo are preferred. 

Essential Q and Essential QS formulary removals:

• ACCURETIC    TAB 10-12.5MG
• ADAPALELE / BENZOYL PEROXIDE GEL 0.1-2.5%
• ADVAIR DISKUS
• AUGMENTIN    SUSPENSION 125 / 5ML
• CALCIPOTRIEN OINTMENT 0.005%
• CARDIZEM LA TAB 120MG 
• CEPHALEXIN   TAB 250MG, 500MG
• CETRAXAL SOLUTION 0.2%
• CHOLESTYRAMINE POWDER PACKET 4GM
• CHOLESTYRAMINE POWDER PACKET 4GM LITE
• CLOPIDOGREL TAB 300MG
• DILTIAZEM ER TAB 120MG, 180MG, 240MG, 300MG, 360MG, 420MG
• DIURIL SUSPENSION 250 / 5ML
• DUTASTERIDE/TAMSULOSIN CAP 0.5-0.4MG
• EPOGEN 
• EVEKEO ODT 
• FIRVANQ  
• FLOVENT DISKUS 
• FLOVENT HFA
• FUROSEMIDE SOLUTION 40MG / 5ML
• GRANIX 
• HALDOL DECAN INJ 
• IBRANCE 
• IMCIVREE INJ 10MG / ML
• ISOTRETINOIN CAP 25MG, 35MG
• ISRADIPINE   CAP 5MG
• LEVOCETIRIZINE SOL 2.5 / 5ML
• LOTEPREDNOL ETABONATE OPHTH GEL 0.5% 
• MATZIM LA TAB 
• MOZOBIL INJ 
• NEULASTA
• NEUPOGEN 
• NICARDIPINE CAP 20MG, 30MG
• NISOLDIPINE TAB ER 20MG, 25.5MG, 30MG, 40MG
• NITROMIST AER 400MCG
• NITYR 
• NYVEPRIA INJ 6 / 0.6ML
• OMNIPOD PDM KIT CLASSIC 
• ORALAIR SUB 300 IR
• PALYNZIQ 
• PREPIDIL GEL 0.5MG / 3G 
• PREVALITE POWDER PACKET 4GM
• PRILOSEC POWDER 2.5MG, 10MG
• PROCRIT 
• PROPARACAINE SOL 0.5% OP
• QUINAPRIL / HCTZ TAB
• RIBAVIRIN INH 6GM
• SODIUM PHENYLBUTYRATE TAB 500MG
• SYMJEPI
• TELMISARTAN / AMLODIPINE TAB
• TELMISARTAN / HCTZ TAB
• VICTOZA 
• VERAPAMIL    CAP 100MG ER, 200MG ER
• VYVANSE 

Essential C formulary removals

• ACCURETIC TAB 10-12.5MG
• ADVAIR DISKUS
• AUGMENTIN SUSPENSION 125 / 5ML
• CEPHALEXIN TAB 500MG
• CETRAXAL SOLUTION 0.2%
• CHOLESTYRAM POWDER PACKET 4GM
• CHOLESTYRAM POWDER PACKET 4GM LITE
• CLOPIDOGREL TAB 300MG
• DIURIL SUSPENSION 250 / 5ML
• DUTASTERIDE / TAMSULOSIN CAP 0.5-0.4
• FIRVANQ
• FLOVENT DISKUS
• FLOVENT HFA
• HALDOL DECAN INJ
• IBRANCE
• ISOTRETINOIN CAP 25MG, 35MG
• ISRADIPINE   CAP 5MG
• LOTEPREDNOL ETABONATE OPHTH GEL 0.5% 
• NICARDIPINE CAP 20MG, 30MG
• NISOLDIPINE TAB 20MG, 25.5MG, 30MG, 40MG ER
• NITROMIST AER 400MCG
• NITYR 
• OMNIPOD PDM KIT CLASSIC 
• ORALAIR SUB 300 IR
• PALYNZIQ 
• PREVALITE POWDER PACKET 4GM
• PROPARACAINE SOL 0.5% OP
• QUINAPRIL / HCTZ TAB 
• SODIUM PHENYLBUTYRATE TAB 500MG
• SYMJEPI 
• TELMISARTAN / AMLODIPINE TAB 
• TELMISARTAN / HCTZ TAB 
• VERAPAMIL    CAP 100MG ER, 200MG ER
• VICTOZA 
• VYVANSE

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