Effective October 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 coverage details with our Commercial and Medicare prior authorization drug search tools.

Blue Cross NC is making these changes for several 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 use our find care page for 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).

New requirements

Adderall tablets, Adzenys XR tablets, Aptensio XR capsule, Azstarys capsules, Cotempla XR tablets, Daytrana patch, Dexedrine CR capsules, Dextroamphetamine ER capsules, Dextroamphetamine tablets, Dyanavel XR suspension and tablets, Focalin tablets, Focalin XR capsules, Jornay PM ER capsules, Metadate CD capsules, Methylin solution, Methylphenidate chewable tablets, Methylphenidate ER tablets, Methylphenidate LA capsule, Mydayis capsules, Procentra solution, Quillichew ER chewable tablet, Quillivant XR suspension, Relexxii ER tablets, Ritalin LA capsules, Ritalin tablets, Vyvanse capsules, Vyvanse chewable tablets, Xelstrym pads, Zenzedi tablets – These medications and their generics (if applicable) will require Quantity Limits across all formularies.

Adderall XR capsules and Concerta tablets – These medications will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. These medications have a generic equivalent on the formulary. These medications and their generics (if applicable) will require Quantity Limits across all formularies.

Eohilia suspension – This medication will require Prior Authorization review on the Enhanced formularies, Non-Formulary review on the Essential formularies, and Value Prior Authorization on the Net Results formularies. Swallowed budesonide nebulizer suspension is preferred. This medication will also require a Quantity Limit across all formularies. Current utilizers will receive a short-term 12-week authorization to allow members to finish the treatment course.

OneTouch Ultra, OneTouch Ultra Blue Test Strips, OneTouch Ultra Test Strips, OneTouch Verio Test Strips, OneTouch Ultra Control, OneTouch Ultra Control Solution, OneTouch Verio Level 3 Control Solution, and OneTouch Verio Level 4 Control Solution – These products will require Step Therapy on the Enhanced formularies, Non-Formulary review on the Essential formularies, and Value Prior Authorization on the Net Results formularies. Abbott (e.g., Freestyle Lite test strips, etc.) and Ascensia (e.g., Contour Next test strips, etc.) test strip products will be preferred.

Updated requirements

Aptiom tablets and Brilinta tablets – These medications will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. These medications have a generic equivalent on the formulary.

Fycompa tablets – This medication will require Non-Formulary review on the Essential formularies. This medication has a generic equivalent on the formulary.

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

Repatha – Quantity limits have been updated to daily maximum of 3 pens for 28 days and for the 140mg/mL strength and 1 pen for 28 days for the 420mg/mL strengths.

Soolantra 1% cream – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. Ivermectin 1% cream (generic Soolantra) will be preferred.

Tolvaptan (generic Jynarque) – This medication will require non-formulary review on the Essential formularies and Value Prior Authorization on the Net Results formulary. Brand Jynarque is preferred.

Essential Q/QS formulary removals

• Adderall XR 5mg, 10mg, 15mg, 20mg, 25mg, and 30mg capsules
• Aptiom 200mg, 400mg, 600mg, and 800mg tablets
• Brilinta 60mg and 90mg tablets
• Concerta 18mg, 27mg, 36mg, and 54mg tablets
• Fycompa 2mg, 4mg, 6mg, 8mg, 10mg, and 12mg tablets
• OneTouch Ultra
• OneTouch Ultra Blue Test Strips
• OneTouch Ultra Test Strips
• OneTouch Verio Test Strips
• OneTouch Ultra Control
• OneTouch Ultra Control Solution
• OneTouch Verio Level 3 Control Solution
• OneTouch Verio Level 4 Control Solution
• Soolantra 1% cream
• Tasigna 150mg capsules
• Promacta 12.5mg and 25mg tablets and powder, 50mg and 75mg tablets
• Tolvaptan 15mg tablet and pack, 30mg tablet and 30-15mg, 45-15mg, 60-30mg and 90-30mg packs

Essential C formulary removals

• Adderall XR 5mg, 10mg, 15mg, 20mg, 25mg, and 30mg capsules
• Aptiom 200mg, 400mg, 600mg, and 800mg tablets
• Brilinta 60mg and 90mg tablets
• Concerta 18mg, 27mg, 36mg, and 54mg tablets
• OneTouch Ultra
• OneTouch Ultra Blue Test Strips
• OneTouch Ultra Test Strips
• OneTouch Verio Test Strips
• OneTouch Ultra Control
• OneTouch Ultra Control Solution
• OneTouch Verio Level 3 Control Solution
• OneTouch Verio Level 4 Control Solution
• Qsymia 11.25-69mg, 15-92mg, 3.75-23mg, 7.5-46mg ER 24hr capsules
• Fycompa 2mg, 4mg, 6mg, 8mg, 10mg, and 12mg tablets
• Soolantra 1% cream
• Tasigna 150mg capsules
• Promacta 12.5mg and 25mg tablets and powder, 50mg and 75mg tablets
• Tolvaptan 15mg tablet and pack, 30mg tablet and 30-15mg, 45-15mg, 60-30mg and 90-30mg packs

Net results – value prior authorization will be required

• Adderall XR 5mg, 10mg, 15mg, 20mg, 25mg, and 30mg capsules
• Aptiom 200mg, 400mg, 600mg, and 800mg tablets
• Brilinta 60mg and 90mg tablets
• Concerta 18mg, 27mg, 36mg, and 54mg tablets
• OneTouch Ultra
• OneTouch Ultra Blue Test Strips
• OneTouch Ultra Test Strips
• OneTouch Verio Test Strips
• OneTouch Ultra Control
• OneTouch Ultra Control Solution
• OneTouch Verio Level 3 Control Solution
• OneTouch Verio Level 4 Control Solution
• Qsymia 11.25-69mg, 15-92mg, 3.75-23mg, 7.5-46mg ER 24hr capsules
• Soolantra 1% cream
• Tolvaptan 15mg tablet and pack, 30mg tablet and 30-15mg, 45-15mg, 60-30mg and 90-30mg packs

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