Effective October 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.

New Requirements

• Auvi-Q, Clomid, Crinone 8% Vaginal Gel, Endometrin 100 mg Suppositories, Epinephrine Auto-Injectors, EpiPen, EpiPen Jr., Menopur, Savella, Symjepi – These medications and their generics (if applicable) will require Quantity Limits across all formularies.
• Brand Estrogel Gel – 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.
• Brand Morphine Sulfate 10 mg/5 mL Oral Solution, Brand Morphine Sulfate 100 mg/5 mL (20 mg/5 mL) Oral Solution, Brand Rectiv – These medications will require Value Prior Authorization on the Net Results formulary. These medications have generic equivalents on the formulary.
• Bromfenac Sodium 0.075% Ophthalmic Solution – This medication will require Value Prior Authorization on the Net Results formulary. Diclofenac sodium 0.1% ophthalmic solution and ketorolac tromethamine 0.5% ophthalmic solution are preferred.
• Cyanocobalamin 500 mcg/0.1 mL Nasal Spray (generic Nascobal) – This medication will require Value Prior Authorization on the Net Results formulary. Cyanocobalamin 1000 mcg/mL injections are preferred.
• Metronidazole 375 mg Capsule – This medication will require Value Prior Authorization on the Net Results formulary. Metronidazole 250 mg or 500 mg tablets are preferred.
• Trudhesa – This medication will require Value Prior Authorization on the Net Results formulary. Dihydroergotamine injections are preferred.

Updated Requirements

• Juxtapid – Quantity limits have been updated to daily maximum of 1 capsule for 5 mg and 10 mg strengths and daily maximum of 2 capsules for 20 mg and 30 mg strengths.
• Simlandi – This medication will be added as a preferred adalimumab biosimilar on Enhanced and Essential formularies. Preferred adalimumab products are Hadlima, Humira and Simlandi on Enhanced and Essential formularies.

Essential C and Q/QS formulary removals

• Estrogel Gel

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