Effective December 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. 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 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
Brand Vyvanse Capsules – Due to shortage issues with lisdexafetamine (generic Vyvanse) capsules, brand Vyvanse was temporarily added back to the formularies in February 2024. Since shortages are improving, we will be removing brand Vyvanse capsules from the Essential formularies, effective November 1, 2025. Therefore, brand Vyvanse capsules will require Non-Formulary review on the Essential formularies. The generic equivalent will be available on the Essential formularies. If lisdexafetamine (generic Vyvanse) capsules are not available at the pharmacy due to shortage issues, pharmacists will be allowed to dispense brand Vyvanse capsules by submitting an override.
Essential Q / QS Formulary Removals
- Vyvanse 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, and 70 mg capsules
Essential C Formulary Removals
- Vyvanse 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, and 70 mg capsules
If you have any questions, please call the Provider Blue Line℠ at 800-214-4844.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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