Blue Cross NC Pharmacy Utilization Management 60-Day Network Notice

Effective April 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 the 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

• Oracea (doxycycline monohydrate DR) 40mg – Brand and generic Oracea will require Value Prior Authorization on the Net Results formularies. This medication already requires Prior Authorization on the Enhanced formularies and requires non-formulary review on the Essential formularies. Generic doxycycline hyclate 20mg tablets, doxycycline monohydrate 50mg tablets, and doxycycline monohydrate 50mg capsules are preferred.

Essential Q/QS formulary removals

• Methotrexate 1gm/40mL and 25mg/mL injections
• Sajazir 30mg/3mL injection
• Sprycel 20mg, 50mg, 70mg, 80mg, 100mg, 140mg tablets

Essential C formulary removals

• Methotrexate 1gm/40mL and 25mg/mL injections
• Sajazir 30mg/3mL injection
• Sprycel 20mg, 50mg, 70mg, 80mg, 100mg, 140mg tablets

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