Publication Date:
2022-11-03
Effective January 1, 2023, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have changes to our pharmacy utilization management (UM) requirements.
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).
Below is a summary of the changes, and more details can be found here.
NEW REQUIREMENTS
Carbatrol capsule, Digoxin solution, Dilantin chew/suspension/tablet, Lanoxin tablet, Lithobid tablet, Mysoline tablet, Neoral capsule/solution, Norpace capsule, Phenytek capsule, Prograf capsule, Rapamune tablet/solution, Sandimmune capsule, Tegretol tablet/solution, Tegretol-XR tablet, Zarontin capsul/solution, Zortress tablet – These Brand products with available generic alternatives will require Prior Authorization on the Essential formularies for members new to therapy. Members will be required to trial the generic product prior to the approval of the brand.
Dymista– This medication and its generic will require Step Therapy on the Essential formularies. The Step Therapy requirement is two over-the-counter intranasal steroid medications.
UPDATED REQUIREMENTS
Mounjaro 2.5mg injection – Quantity Limit reduced from 8 injections per month to 4 injections per 180 days on all formularies.
Rybelsus 3mg tablet – Quantity Limit reduced from 1 tablet per day to 30 tablets per 180 days on all formularies.
FORMULARY CHANGES
Xiidra 5% Drops – This medication will be removed from all Essential formularies. Members with claims for Xiidra 5% drops in the last 120 days will automatically receive an authorization for Restasis 0.05% single dose vial effective 1/1/2023.
Brand Vagifem – This medication will be removed from all Essential formularies and the generic version, estradiol 10mg tablet, will be added to formulary as the preferred product.
Essential 6 Tier (Essential Q) formulary removals
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ARAKODA TAB 100MG |
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AMCINONIDE LOT 0.1% |
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IMBRUVICA 280MG TAB |
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KRINTAFEL TAB 150MG |
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LAMICTAL XR KIT |
|
NUVESSA GEL 1.3% |
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PRADAXA CAP 150MG |
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SUPREP BOWEL SOL PREP KIT |
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TAZORAC GEL 0.05% |
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TAZORAC GEL 0.1% |
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VAGIFEM |
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VIIBRYD STARTER PACK |
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XIIDRA DRO 5% |
Essential 5 Tier (Essential C) formulary removals
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ACYCLOVIR OIN 5% |
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ADAPAL/BEN P GEL 0.1-2.5% |
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ALMOTRIP MAL TAB 12.5MG |
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ALMOTRIP MAL TAB 6.25MG |
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ALOCRIL SOL 2% |
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ALOMIDE SOL 0.1% OP |
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ALTABAX OIN 1% |
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AMCINONIDE LOT 0.1% |
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AMOXAPINE TAB 100MG |
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AMOXAPINE TAB 150MG |
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AMOXAPINE TAB 25MG |
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AMOXAPINE TAB 50MG |
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APADAZ TAB 4.08-325 |
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APADAZ TAB 6.12-325 |
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APADAZ TAB 8.16-325 |
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ARAKODA TAB 100MG |
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BEPOTASTINE DRO 1.5% |
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BESIVANCE SUS 0.6% |
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BRINZOLAMIDE SUS 1% |
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BUPRENORPHIN DIS 10MCG/HR |
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BUPRENORPHIN DIS 15MCG/HR |
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BUPRENORPHIN DIS 20MCG/HR |
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BUPRENORPHIN DIS 5MCG/HR |
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BUPRENORPHIN DIS 7.5/HR |
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BUSPIRONE TAB 7.5MG |
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CALCIPOTRIEN OIN 0.005% |
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CALCITRENE OIN 0.005% |
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CALCITRIOL OIN 3MCG/GM |
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CARISOPRODOL TAB 250MG |
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CARISOPRODOL TAB 350MG |
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CEFACLOR SUS 125/5ML |
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CEFACLOR SUS 250/5ML |
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CEFACLOR SUS 375/5ML |
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CEPHALEXIN TAB 250MG |
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CIMETIDINE SOL 300/5ML |
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CIMETIDINE SOL 400MG |
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CLOCORTOLONE CRE 0.1% |
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CONSENSI TAB 10-200MG |
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CONSENSI TAB 2.5-200 |
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CONSENSI TAB 5-200MG |
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DARIFENACIN TAB 15MG |
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DARIFENACIN TAB 7.5MG |
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DESLORATADIN TAB 2.5 ODT |
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DESLORATADIN TAB 5MG ODT |
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DEXILANT CAP 30MG DR |
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DEXILANT CAP 60MG DR |
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DIFLORASONE CRE 0.05% |
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DIFLUPREDNAT EMU 0.05% |
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EPINASTINE DRO 0.05% |
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EPOGEN INJ 10000/ML |
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EPOGEN INJ 2000/ML |
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EPOGEN INJ 20000/ML |
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EPOGEN INJ 3000/ML |
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EPOGEN INJ 4000/ML |
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ERGOLOID MES TAB 1MG ORAL |
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ERTACZO CRE 2% |
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ERY/BENZOYL GEL 3-5% |
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EVEKEO ODT TAB 10MG |
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EVEKEO ODT TAB 5MG |
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EXELDERM SOL 1% |
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FEBUXOSTAT TAB 40MG |
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FEBUXOSTAT TAB 80MG |
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FENOPROFEN TAB 600MG |
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FLUOXETINE TAB 10MG |
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FLUVASTATIN CAP 20MG |
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FLUVASTATIN CAP 40MG |
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FROVATRIPTAN TAB 2.5MG |
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FULPHILA INJ 6/0.6ML |
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FUROSEMIDE SOL 8MG/ML |
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GRANIX INJ 300/0.5 |
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GRANIX INJ 300/1ML |
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GRANIX INJ 480/0.8 |
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GRANIX INJ 480/1.6 |
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HALDOL DECAN INJ 100MG/ML |
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HALDOL DECAN INJ 50MG/ML |
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HALOG OIN 0.1% |
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HC BUTYRATE CRE 0.1% |
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HC BUTYRATE SOL 0.1% |
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HYDROCO/APAP TAB 10-300MG |
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HYDROCO/APAP TAB 5-300MG |
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HYDROCO/APAP TAB 7.5-300 |
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HYDROCODONE TAB 100MG ER |
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HYDROCODONE TAB 120MG ER |
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HYDROCODONE TAB 20MG ER |
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HYDROCODONE TAB 30MG ER |
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HYDROCODONE TAB 40MG ER |
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HYDROCODONE TAB 60MG ER |
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HYDROCODONE TAB 80MG ER |
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HYDROMORPHON TAB 12MG ER |
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HYDROMORPHON TAB 16MG ER |
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HYDROMORPHON TAB 32MG ER |
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HYDROMORPHON TAB 8MG ER |
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ILEVRO DRO 0.3% OP |
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IMBRUVICA 280MG TAB |
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IMCIVREE INJ 10MG/ML |
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INFASURF SUS 35MG/ML |
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IRBESAR/HCTZ TAB 150-12.5 |
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IRBESAR/HCTZ TAB 300-12.5 |
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KADIAN CAP 200MG ER |
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KETOPROFEN CAP 200MG ER |
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KRINTAFEL TAB 150MG |
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LAMICTAL XR KIT |
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LANSOPR/AMOX MIS /CLARITH |
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LANSOPRAZOLE TAB 15MG ODT |
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LANSOPRAZOLE TAB 30MG |
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LANSOPRAZOLE TAB 30MG ODT |
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LASTACAFT SOL 0.25% |
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LEVOCETIRIZI SOL 2.5/5ML |
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LEVORPHANOL TAB 2MG |
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LEVORPHANOL TAB 3MG |
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LUBIPROSTONE CAP 24MCG |
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LUBIPROSTONE CAP 8MCG |
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LUMIGAN SOL 0.01% |
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MAPROTILINE TAB 25MG |
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MAPROTILINE TAB 50MG |
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MAPROTILINE TAB 75MG |
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MECLOFEN SOD CAP 100MG |
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MECLOFEN SOD CAP 50MG |
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MEPROBAMATE TAB 200MG |
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MEPROBAMATE TAB 400MG |
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METAXALONE TAB 400MG |
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METAXALONE TAB 800MG |
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METHAMPHETAM TAB 5MG |
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MORPHINE SUL CAP 40MG ER |
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MOZOBIL INJ |
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NAFTIFINE CRE HCL 1% |
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NEBIVOLOL TAB 10MG |
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NEBIVOLOL TAB 2.5MG |
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NEBIVOLOL TAB 20MG |
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NEBIVOLOL TAB 5MG |
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NEFAZODONE TAB 100MG |
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NEFAZODONE TAB 150MG |
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NEFAZODONE TAB 200MG |
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NEFAZODONE TAB 250MG |
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NEFAZODONE TAB 50MG |
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NEULASTA INJ 6MG/0.6M |
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NEULASTA KIT 6MG/0.6M |
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NEUPOGEN INJ 300/0.5 |
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NEUPOGEN INJ 300MCG |
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NEUPOGEN INJ 480/0.8 |
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NEUPOGEN INJ 480MCG |
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NIZATIDINE CAP 150MG |
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NIZATIDINE CAP 300MG |
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NIZATIDINE SOL 15MG/ML |
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NUVESSA GEL 1.3% |
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NYSTAT/TRIAM CRE |
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NYVEPRIA INJ 6/0.6ML |
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OLOPATADINE SPR 0.6% |
|
OMEPRA/BICAR POW 20-1680 |
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OMEPRA/BICAR POW 40-1680 |
|
ONGENTYS CAP 25MG |
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ONGENTYS CAP 50MG |
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OTOVEL DRO |
|
OXICONAZOLE CRE NITRATE |
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PEG/NASUL/C/ SOL NACL/POT |
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PHOSPHOLINE SOL 0.125%OP |
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PRADAXA CAP 150MG |
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PREPIDIL GEL 0.5MG/3G |
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PRILOSEC POW 10MG |
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PRILOSEC POW 2.5MG |
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PROCRIT INJ 10000/ML |
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PROCRIT INJ 2000/ML |
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PROCRIT INJ 20000/ML |
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PROCRIT INJ 3000/ML |
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PROCRIT INJ 4000/ML |
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PROCRIT INJ 40000/ML |
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PROSTIN E2 SUP 20MG |
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PSORCON CRE 0.05% |
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RABEPRAZOLE TAB 20MG |
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RAMELTEON TAB 8MG |
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RIBAVIRIN INH 6GM |
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SAVELLA MIS TITR PAK |
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SAVELLA TAB 100MG |
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SAVELLA TAB 12.5MG |
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SAVELLA TAB 25MG |
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SAVELLA TAB 50MG |
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SILODOSIN CAP 4MG |
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SILODOSIN CAP 8MG |
|
SOLOSEC GRA 2GM |
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SUPREP BOWEL SOL PREP KIT |
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TAZORAC GEL 0.05% |
|
TAZORAC GEL 0.1% |
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TESTOSTERONE GEL 1%(50MG) PACKETS |
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TESTOSTERONE GEL PUMP 1% |
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THIORIDAZINE TAB 100MG |
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THIORIDAZINE TAB 10MG |
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THIORIDAZINE TAB 25MG |
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THIORIDAZINE TAB 50MG |
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TRAVOPROST DRO 0.004% |
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TRIAZOLAM TAB 0.125MG |
|
TRIAZOLAM TAB 0.25MG |
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TUZISTRA XR SUS |
|
VAGIFEM |
|
VANADOM TAB 350MG |
|
VIIBRYD STARTER PACK |
|
XIIDRA DRO 5% |
|
ZERVIATE DRO 0.24% |
|
ZILEUTON ER TAB 600MG |
|
ZIRGAN GEL 0.15% |
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ZUBSOLV SUB 0.7-0.18 |
|
ZUBSOLV SUB 1.4-0.36 |
|
ZUBSOLV SUB 11.4-2.9 |
|
ZUBSOLV SUB 2.9-0.71 |
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ZUBSOLV SUB 5.7-1.4 |
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ZUBSOLV SUB 8.6-2.1 |
If you have any questions, please call the Provider Blue LineSM at 1-800-214-4844.
Blue Connect