Blue Cross NC Pharmacy Utilization Management 60-Day Network Notice

Effective January 1, 2025, 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. Visit the Blue Cross NC commercial drug search for 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 on our website.

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).

Updated requirements

Actemra – This medication will require non-formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Tyenne is preferred.

Brand Corlanor tablet – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. This medication has a generic equivalent on the formulary.

Endari – This medication will require non-formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Glutamine (sickle cell) powder is preferred.

Dexlansoprazole capsule (generic Dexilant) – This medication will require Step Therapy on the Essential Q formulary and requires non-formulary review on Essential C. Pantoprazole and OTC PPIs (such as omeprazole and esomeprazole) are preferred. Note that OTC PPIs are a benefit exclusion for Fully Insured members on the Essential formularies.

Omeprazole-Sodium Bicarbonate Power Packet for Suspension 20-1680mg, 40-1680mg – 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 (Zegerid OTC).

Phenylephrine ophthalmic solution 2.5%, 10% – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. This medication is typically used in the medical setting.

Tetracaine ophthalmic solution 0.5% – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. This medication is typically used in the medical setting.

In an effort to keep health care as affordable as possible and expand access, adalimumab-aaty and adalimamab-adaz will be added to Essential and Net Results formularies. The Biologic Immunomodulators criteria will be updated to prefer adalimumab- aaty, adalimumab-adaz, Hadlima™, Humira® and Simlandi® across all formularies. Existing prior authorizations for Hadlima, Humira and Simlandi will continue to be active until the original approval end date.

Essential Q/QS formulary removals

• ACTEMRA
• AZEL/FLUTIC – SPR 137-50
• CERVIDIL – VAG MIS 10MG INS
• CORLANOR – TAB
• DILTIAZEM – CAP 360MG ER
• DOXERCALCIF – CAP 0.5MCG, 1MCG, 2.5MCG
• ENDARI
• ESTRADIOL – GEL 0.06%
• ESTRADIOL – GEL 0.25MG, 0.5MG, 0.75MG, 1MG, 1.25MG
• HC BUTYRATE – CRE 0.1%
• HYDROC/HOMAT – TAB 5-1.5MG
• ISOSORB DIN – TAB 40MG
• ISRADIPINE – CAP 2.5MG
• LUMIGAN – SOL 0.01% OP
• OMEPRA/BICAR – POW 20-1680, 40-1680
• PENTAZ/NALOX – TAB 50-0.5MG
• PHOSPHOLINE – SOL 0.125%OP
• PRADAXA – PAK 20MG, 30MG, 40MG, 50MG, 110MG, 150MG
• TESTOSTERONE – SOL 30MG/ACT
• TRANDO/VERAP – TAB 1-240 ER, 2-180 ER, 2-240 ER, 4-240 ER
• TRIHEXYPHEN – TAB 5MG
• VERAPAMIL – CAP 300MG ER
• VERAPAMIL – CAP 360MG SR
  
  

Essential C formulary removals

•  ACTEMRA – INJ 162/0.9, ACTPEN
• AUGMENTIN – SUS 125/5ML
• BRIMO/TIMOLO – SOL 0.2/0.5%
• BROMFENAC – SOL 0.09% OP
• CEPHALEXIN – TAB 500MG
• CERVIDIL – VAG MIS 10MG INS
• CETRAXAL – SOL 0.2%
• CHOLESTYRAM – POW 4GM, 4GM LITE
• CORLANOR – TAB
• CROTAN – LOT 10%
• DILTIAZEM – CAP 360MG ER
• DOXERCALCIF – CAP 0.5MCG, 1MCG, 2.5MCG
•  EMSAM – DIS 6MG/24H, 9G/24H, 12MG/24H
• ENDARI
• ERGOT/CAFFEN – TAB 1-100MG
• ESTRADIOL – GEL 0.06%
• ESTRADIOL – GEL 0.25MG, 0.5MG, 0.75MG, 1MG, 1.25MG
• FLAVOXATE – TAB 100MG
• HYDROC/HOMAT – TAB 5-1.5MG
• ISOSORB DIN – TAB 40MG
• ISRADIPINE – CAP 2.5MG
• MATZIM – LA TAB 180MG/24, 240MG/24, 300MG/24, 360MG/24, 420MG/24
• MEFENAM ACID – CAP 250MG
• HENYLEPHRIN – SOL 2.5% OP, 10% OP
• PRADAXA – PAK 20MG, 30MG, 40MG, 50MG, 110MG, 150MG
• PROPARACAINE – SOL 0.5% OP
• TESTOSTERONE – SOL 30MG/ACT
• TETRACAINE – SOL 0.5% OP
• THEOPHYLLINE – TAB 100MG ER, 200MG ER
• TRANDO/VERAP – TAB 1-240 ER, 2-180 ER, 2-240 ER, 4-240 ER
• TRIHEXYPHEN – TAB 5MG
• VERAPAMIL – CAP 300MG ER
• VERAPAMIL – CAP 360MG SR
  

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