Effective October 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). 

New Requirements 

Elmiron (pentosan polysulfate sodium) 100mg capsules – This medication will require Quantity Limits (3 capsules per day) across all formularies. 

Ranitidine 150mg and 300mg tablets – This medication will be a benefit exclusion for Fully Insured members on the Enhanced and Essential formularies as well as ASO members on Net Results full due to the availability of similar over-the-counter versions of the product (famotidine OTC).  

Xdemvy (lotilaner) 0.25% ophthalmic solution – This medication will require Prior Authorization review on the Enhanced and Essential formularies, and it will require Quantity Limits across all formularies. 

Updated Requirements

Austedo (deutetrabenazine) tablets/XR tablets – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. Ingrezza (valbenazine) capsules/sprinkle capsules are preferred.   

Bosulif (bosutinib) tablets, Farxiga (dapagliflozin) tablets, Januvia tablets, Janumet tablets, Ofev (nintedanib esylate) capsules, Xeljanz (tofacitinib) tablets/solution/XR tablets, Xigduo XR 5-500mg, 5-1000mg, 10-500mg, and 10-1000mg tablets – 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. 

Midazolam 10 mg/0.7mL auto-injector solution – This medication will no longer be covered under the pharmacy benefit because it must be administered by a health care provider. It may be covered under the medical benefit.  

Pomalyst (pomalidomide) – This medication will require Value Prior Authorization on the Net Results formularies. It has generic equivalents on the formulary. 

Essential Q/QS Formulary Removals

• Austedo tablets and Austedo XR tablets 
• Bosulif tablets 
• Farxiga tablets 
• Januvia tablets 
• Janumet tablets 
• Ofev capsules 
• Xeljanz tablets, Xeljanz solution, and Xeljanz XR tablets 
• Xigduo XR 5-500mg, 5-1000mg, 10-500mg, and 10-1000mg, tablets 

Essential C Formulary Removals

• Austedo tablets and Austedo XR tablets 
• Bosulif tablets 
• Farxiga tablets 
• Januvia tablets 
• Janumet tablets 
• Ofev capsules 
• Xeljanz tablets, Xeljanz solution, and Xeljanz XR tablets 
• Xigduo XR 5-500mg, 5-1000mg, 10-500mg, and 10-1000mg, tablets 

Net Results – Value Prior Authorization will be required

• Austedo tablets and Austedo XR tablets 
• Bosulif tablets 
• Farxiga tablets 
• Januvia tablets 
• Janumet tablets 
• Hemangeol (propranolol) 4.28mg/ml solution 
• Ofev capsules 
• Pomalyst capsules 
• Xeljanz tablets, Xeljanz solution, and Xeljanz XR tablets 
• Xigduo XR 5-500mg, 5-1000mg, 10-500mg, and 10-1000mg, tablets 

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