Effective July 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. View more details.

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.

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

• Alrex, Bromsite – These medications will require Value Prior Authorization on the Net Results formulary, but they have generic equivalents on formulary.
• Ciclopirox 0.77% gel, Clindamycin 1% solution, Econazole 1% cream, Erythromycin 2% solution, Erygel 2% gel, Gentamicin 0.1% cream and ointment, Ketoconazole 2% cream, Loprox 0.77% suspension and cream, Myrbetriq, Tobramycin 0.3% ophthalmic solution, Vancocin – These medications and their generics (if applicable) will require Quantity Limits across all formularies.
• Clindamycin Phosphate/Benzoyl Peroxide 1.2-2.5% and1.2-3.75% Gel – This medication will require Value Prior Authorization on the Net Results formulary. Clindamycin phosphate/benzoyl peroxide 1.2-5% (refrigerated) is preferred.
• Gralise 300mg and 600mg – This medication will require Value Prior Authorization on the Net Results formulary. Generic gabapentin is preferred.
• Nascobal – This medication will require Value Prior Authorization on the Net Results formulary. Cyanocobalamin injections are preferred.
• Pitavastatin (Generic Livalo) – This medication will require Value Prior Authorization on the Net Results formulary. Preferred products include atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin.
• Xiidra – This medication will require Value Prior Authorization on the Net Results formularies. Restasis single dose vials and Tyrvaya are preferred.

UPDATED REQUIREMENTS

• Amjevita – This medication will require additional Step Therapy on the Enhanced formularies, will require Non-Formulary review on the Essential formularies, and Value Prior Authorization on the Net Results formulary. Preferred products are Hadlima and Humira on Enhanced and Essential formularies and Humira and Cyltezo on the Net Results formulary.
• Brand Forteo, Brand Korlym – These medications will require additional Step Therapy on the Enhanced formularies, will require Non-Formulary review on the Essential formularies, and Value Prior Authorization on the Net Results formulary. These medications have generic equivalents on the formulary.
• Brand Thiola EC – This medication will require Non-Formulary review on the Essential formularies. Tiopronin delayed release (generic Thiola EC) is preferred.
• Exkivity – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary.
• Granix, Neulasta, Neupogen – These medications will require Value Prior Authorization on the Net Results formulary. Preferred products include Nyvepria and Fulphilia and will not require PA.

Essential Q/QS formulary removals

• Amjevita 10mg/0.2mL, 20mg/0.2mL, 20mg/0.4mL, 40mg/0.4mL, 40mg/0.8mL, and 80mg/0.8mL injection
• Exkivity 40mg capsule
• Forteo 600mcg/2.4mL injection
• Korlym 300mg tablets
• Pradaxa 100mg capsule
• Thiola EC 100mg, 300mg tablet 

Essential C formulary removals

• Amjevita 10mg/0.2mL, 20mg/0.2mL, 20mg/0.4mL, 40mg/0.4mL, 40mg/0.8mL, and 80mg/0.8mL injection
• Exkivity 40mg capsule
• Forteo 600mcg/2.4mL injection
• Korlym 300mg tablets
• Pradaxa 110mg capsule
• Thiola EC 100mg, 300mg tablet

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