Effective July 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).

New requirements

Trokendi XR and Qudexy XR capsules - These medications and their generics (if applicable) will require Quantity Limits across all formularies.

Xenazine - This medication will require trial and failure of generic tetrabenazine.

Update requirements

Lantus and Lantus Solostar – These medications will require Step Therapy on the Enhanced formularies, non-formulary review on the Essential formularies, and Value Prior Authorization on the Net Results formularies. Semglee and Insulin Glargine-YFGN are preferred. Lantus, Semglee, and Insulin Glargine-YFGN are interchangeable biosimilars and do not require a new prescription at the pharmacy.

Topiramate ER 25mg, 50mg, 100mg, and 200mg capsules (generic Trokendi XR) – This medication will require non-formulary review on the Essential formularies. Members with a seizure diagnosis that are using this mediation will automatically receive an authorization for a non-formulary exception effective 7/1/2025. For members without a seizure diagnosis, topiramate IR and topiramate ER sprinkle capsules (generic Qudexy XR) are preferred. Generic Qudexy XR requires Prior Authorization on the Essential formularies.

Essential Q/QS formulary removals

• Lantus
• Lantus Solostar
• Nitrolingual 0.4 mg/spray
• Topiramate ER 25mg, 50mg, 100mg, 200mg capsules
• Ocaliva 5, 10mg tablets
• Mesnex 400mg tablets
• Purixan 20mg/mL suspension

Essential C formulary removals

• Lantus
• Lantus Solostar
• Nitrolingual 0.4mg/spray
• Topiramate ER 25mg, 50mg, 100mg, 200mg capsules
• Velphoro
• Ocaliva 5, 10mg tablets
• Mesnex 400mg tablets
• Purixan 20mg/mL suspension

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