Effective January 1, 2026, 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: 

• Taking 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. 
• Implementing ongoing programs, such as utilization management and formulary management, helping us provide our members with access to drugs that are safe, effective, and as cost-efficient as possible. 
• Reviewing medical research and costs of medications regularly to help our members get the most appropriate 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. 
• Encouraging members speak with 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

Estrogen products, testosterone products, and gonadotropin releasing hormone products – Hormone therapies (including estrogens, testosterones, and gonadotropin releasing hormone therapies) may be subject to benefit exclusion based on member benefit. 

Methylphenidate 18 mg, 27 mg, 36 mg, and 54 mg ER tablets – These medications and its generics (if applicable) will require Quantity Limits across all formularies. 

Nyvepria Injection – This medication will require prior authorization and step therapy on Enhanced formularies, Non-Formulary review on Essential formularies and Value Prior Authorization on Net Results formularies. Fulphila and Fylnetra will be preferred. 

Updated Requirements

Dificid tablets and Entresto 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. 

Klor-Con 8 and 10 mEq ER tablets – These medications will require Non-Formulary review on the Essential formularies. These medications have a generic equivalent on the formulary. 

Saxenda injection – This medication will require Non-Formulary review on the Essential C formulary. This medication has a generic equivalent on the formulary. 

Complera tablets, Fycompa tablets, and Safyral tablets – These medications will require Value Prior Authorization on the Net Results formularies. These medications have a generic equivalent on the formulary. 

Galzin capsules – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. Penicillamine, trientine, or OTC zinc is preferred.  

Linzess capsules – This medication will require Value Prior Authorization on the Net Results formulary. Trulance is preferred. 

Spiriva Handihaler – This medication will require Prior Authorization on the Enhanced formularies, Non-Formulary review on the Essential formularies, and Value Prior Authorization on the Net Results formularies. Incruse Ellipta and Spiriva Respimat will be preferred. Spiriva Handihaler and its generic will also continue to require Quantity Limits across all formularies. 

Revlimid capsules and Tracleer tablets for oral suspension – 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. 

Altrixa OB tablet, Pregen DHA capsule, Prenate Max tablet, Primacare capsule, Natal PNV tablet, Prenatol-M 27-1.2 mg tablet – These medications will be benefit exclusions for members on the Enhanced, Essential, and Net Results formularies due to the availability of lower cost prenatal vitamins. 

Promacta tablets and powder packs and Tasigna capsules – These medications will require Value Prior Authorization on the Net Results formularies. These medications have a generic equivalent on the formulary. 

Essential Q/QS Formulary Removals

• Dificid 200 mg tablet
• Entresto 24-26 mg, 49-51 mg, 97-103 mg tablet
• Erythromycin 5 mg/gm ophthalmic ointment
• Fluocinolone acetonide 0.025% cream
• Galzin 25 mg, 50 mg capsules
• Klor-Con 10 10meq ER tablets
• Klor-Con 8 8meq ER tablets
• Spiriva Handihaler
• Revlimid capsules
• Nyvepria injection
• Tracleer tablets for oral suspension
• Hydrocodone/acetaminophen 5-300 mg, 7.5-300 mg, 10-300 mg tablet
• Diflorasone 0.05% cream
• Amlodipine-valsartan-hydrochlorothiazide (generic Exforge HCT) tablets
• Baxdela 450 mg tablet
• Clindesse 2% cream
• Almotriptan malate tablets
• Levorphanol tablets
• Lotemax 0.5% ointment
• Lotemax SM 0.38% gel
• Meclofen sodium 50 mg and 100 mg capsule
• Metaxalone 400 mg tablet
• Methyltestosterone 10 mg capsule
• Frovatriptan 2.5 mg tablet
• Ongentys 25 mg and 50 mg capsule
• Oxycodone 100 mg/5 mL concentrate
• Ryclora 2 mg/5 mL solution
• Solosec 2 gm granule packets
• Teriparatide 620 mcg/2.48 mL injection
• Testosterone 1% gel pump (authorized generic)
• Zerviate 0.24% drops

Essential C Formulary Removals 

• Dificid 200 mg tablet
• Entresto 24-26 mg, 49-51 mg, 97-103 mg tablet
• Erythromycin 5 mg/gm ophthalmic ointment
• Fluocinolone acetonide 0.025% cream
• Flurbiprofen 50 mg tablet
• Flurbiprofen 100 mg tablet
• Flurbiprofen 100 mg tablet
• Galzin 25 mg, 50 mg capsules
• Klor-Con 10 10meq ER tablets
• Klor-Con 8 8meq ER tablets
• Saxenda injection
• Spiriva Handihaler
• Revlimid capsules
• Nyvepria Injection
• Tracleer tablets for oral suspension
• Amlodipine-valsartan-hydrochlorothiazide (generic Exforge HCT) tablets
• Baxdela 450 mg tablet
• Clindesse 2% cream
• Lotemax 0.5% ointment
• Lotemax SM 0.38% gel
• Methyltestosterone 10 mg capsule
• Oxycodone 100 mg/5 mL concentrate
• Kaletra solution
• Prevalite 4 gm powder packet
• Cholestyram 4 gm lite powder packet
• Lamictal XR Kit
• Prenatal 19 tablet
• Cyclogyl 0.5% and 2% ophthalmic solution
• Teriparatide 560 mcg/2.24 mL injection

Net Results – Value Prior Authorization will be required 

• Alendronate sodium 70 mg/75 mL oral solution
• Complera 200-25-300 mg tablet
• Dificid 200 mg tablet
• Entresto 24-26 mg, 49-51 mg, 97-103 mg tablet
• Erythromycin 5 mg/gm ophthalmic ointment
• Fluocinolone acetonide 0.025% cream
• Flurbiprofen 50 mg tablet
• Flurbiprofen 100 mg tablet
• Flurbiprofen 100 mg tablet
• Fycompa 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg tablets
• Galzin 25 mg, 50 mg capsules
• Linzess 72 mcg, 145 mcg, 290 mcg capsules
• Miglitol 25 mg, 50 mg, and 100mg tablets
• Risedronate sodium 5 mg tablets
• Safyral 3-0.03-0.451 mg tablets
• Spiriva Handihaler
• Vuity 1.25% ophthalmic solution
• Revlimid capsules
• Tasigna 50 mg, 150 mg 200 mg capsules
• Promacta 12.5 mg, 25 mg, 50 mg, 75 mg tablets and 12.5 mg, 25 mg powder packs
• Tracleer 32 mg tablets for oral suspension
• Nyvepria Injection

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