Effective July 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 a number of 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 to 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

AspyreRx, EndeavorRx, Leva Pelvic Health System, Luminopia One, Mahana IBS, Rejoyn, reSET, reSET-O, and Somryst – Prescription digital therapeutics will no longer be covered under the pharmacy benefit.

Atrovent HFA (ipratropium bromide HFA), Auryxia (ferric citrate), Briviact (brivaracetam), Edurant (rilpivirine), Pomalyst (pomalidomide), and Savella (milnacipran) – These medications will require Non-Formulary review on the Essential formularies. They will have generic equivalents on the formulary.

Azmiro (testosterone cypionate) and Photrexa/Photrexa viscous kit (riboflavin 5-phosphate ophthalmic) – These medications will no longer be covered under the pharmacy benefit because they must be administered by a healthcare provider. They may be covered under the medical benefit.

Diskets (methadone) and Mavenclad (cladribine) – These medications will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. They will have generic equivalents on the formulary.

Fycompa (perampanel) 0.5mg/mL suspension and Gleostine (lomustine) – These medications will require Value Prior Authorization on the Net Results formularies. They will have generic equivalents on the formulary.

Naftifine 1% cream – This medication will require Non-Formulary review on the Essential Q formulary. Ketoconazole 2% cream, econazole 1% cream, and naftifine 2% cream are preferred.

Otrexup (methotrexate) injection – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. Otrexup was recently discontinued by the manufacturer. Rasuvo (methotrexate) injection is preferred.

Essential Q/QS Formulary Removals

• Atrovent HFA inhaler
• Auryxia tablets
• Briviact tablets and solution
• Diskets tablets
• Edurant tablets
• Mavenclad tablets
• Naftifine 1% cream
• Otrexup injections
• Pomalyst capsules
• Savella tablets and titration pack

Essential C Formulary Removals

• Atrovent HFA inhaler
• Auryxia tablets
• Briviact tablets and solution
• Diskets tablets
• Edurant tablets
• Mavenclad tablets
• Otrexup injections
• Pomalyst capsules

Net Results – Value Prior Authorization will be required

• Mavenclad tablets
• Pomalyst capsules
• Zylet 0.5-0.3% ophthalmic suspension

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