Blue Cross NC Pharmacy Utilization Management 60-Day Network Notice

Effective January 1, 2027, 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 price 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 to 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 apply to 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

K-Phos Tab Neutral, K-Phos Tab No 2, Phospha 250 Tab Neutral – These products are non-FDA approved and will no longer be covered under the pharmacy benefit. Alternative products include Wes-Phos 250 Neutral Tab and K-Phos Tab 500mg.

Ob Complete Cap Petite, Prenate Cap Enhance, Prenate Cap Pixie, Prenate Dha Cap, Prenate Mini Cap, Select-Ob+ Pak Dha, Vitafol Cap Ultra, Vitafol-Ob Pak +Dha, Vitafol-One Cap, Westgel Dha Cap – These products are non-FDA approved and will no longer be covered under the pharmacy benefit. Alternative prenatal vitamins are available on each formulary.

Nuvaring – This medication will require non-formulary review on the Essential formularies and Value Prior Authorization on the ValuePath formulary. Generic equivalents of Nuvaring (EluRyng, Enilloring, Etonogestrel-ethinyl estradiol and Haloette) are available on each formulary.

Ferrous Sulfate 220mg/5ml solution, Ferrous Sulfate 44mg/5ml solution – These medications will no longer be covered under the pharmacy benefit because it is an over-the-counter product.

Novopen Echo – This product will no longer be covered under the pharmacy benefit. It may be covered under the medical benefit.

Humira, Hadlima, Simlandi, Adalimumab-adaz – These medications will require non-formulary review on the Essential formularies and Value Prior Authorization on the ValuePath formulary. Adalimumab-aaty and Adalimumab-adbm are preferred.

Stelara, Selarsdi – These medications will require non-formulary review on the Essential formularies and Value Prior Authorization on the ValuePath formulary. Yesintek, Steqeyma and Ustekinumab-aauz are preferred.

Jynarque – This medication will require non-formulary review on the Essential formularies and Value Prior Authorization on the ValuePath formulary. Generic equivalent is on the formulary.

Epclusa 400/100mg tablet – This medication will require Value Prior Authorization on the ValuePath formulary. Generic equivalent is on the formulary.

Essential Q/QS Formulary Removals

• Nuvaring
• Humira
• Hadlima
• Simlandi
• Adalimumab-adaz
• Stelara
• Selarsdi
• Jynarque

Essential C Formulary Removals

• Nuvaring
• Humira
• Hadlima
• Simlandi
• Adalimumab-adaz
• Stelara
• Selarsdi
• Jynarque

ValuePath – Value Prior Authorization will be required

• Nuvaring
• Humira
• Hadlima
• Simlandi
• Adalimumab-adaz
• Stelara
• Selarsdi
• Jynarque
• Epclusa 400/100mg tablet

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