Effective April 1, 2024, 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. 

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 at http://www.bcbsnc.com/content/services/formulary/drug-search.htm.

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

• Brand and Generic Nascobal – This medication will require Prior Authorization and Step Therapy on the Net Results formulary. Cyanocobalamin injections are preferred. This change will only impact members new to therapy on the Net Results formulary.
• Repatha – This medication will require Prior Authorization and Step Therapy on the Net Results formulary. High-intensity statins are preferred, but Repatha will remain the preferred PCSK9 inhibitor. This change will only impact members new to therapy.
• Symjepi – This medication will require Prior Authorization on the Enhanced formulary. Auvi-Q and generic Epi-Pen are preferred.
• Udenyca and Ziextenzo – These medications will require Prior Authorization and Step Therapy on the Enhanced formularies, Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Preferred products include Nyvepria and Fulphilia.

UPDATED REQUIREMENTS

• Bydureon BCise, Mounjaro, Ozempic, Rybelsus, and Trulicity – Members currently taking these products without a type 2 diabetes diagnosis may require prior authorization. Medical record documentation of a type 2 diabetes diagnosis will be required.
• Forteo – This medication will require additional Step Therapy on the Enhanced, Essential and Net Results formularies. Generic teriparatide is preferred.
• Norditropin – This medication will require Step Therapy on the Enhanced formularies, Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Preferred products include Omnitrope and Genotropin.
• Omnipod Go – This insulin pump will be a benefit exclusion for members on the Enhanced, Essential, and Net Results formularies because it is being removed from the pharmacy benefit. Omnipod Go may be covered under the medical benefit. The Omnipod Dash and Omnipod G6 will remain available for coverage on the pharmacy benefit.
• Reltone and Ursodiol (authorized generic Reltone) – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Brand Reltone will require a step through generic ursodiol 300mg capsules. Ursodiol (authorized generic Reltone) will require a step through both generic ursodiol 300mg capsules and brand Reltone. Medical record documentation will be required for members unable to utilize the preferred products.

Essential Q / QS formulary removals

• Accuretic 10-12.5mg tablet 
• Diastat Acudial 5-10mg, 12.5-20mg gel 
• Norditropin
• Omnipod Go
• Oxandrolone 2.5mg and 10mg tablets 
• Rhofade 1% Cream 
• Risperdal 12.5mg, 25mg, 37.5mg, 50mg injection 
• Udenyca 6mg/0.6mL 
• Votrient 200mg tablet 
• Ziextenzo 6mg/0.6mL

Essential C formulary removals

• Diastat Acudial 5-10mg, 12.5-20mg gel 
• Norditropin 
• Omnipod Go 
• Oxandrolone 2.5mg and 10mg tablet
• Risperdal 12.5mg, 25mg, 37.5mg, 50mg injection 
• Udenyca 6mg/0.6mL 
• Votrient 200mg tablet 
• Ziextenzo 6mg/0.6mL

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