Blue Cross NC Pharmacy Utilization Management 60-day network notice

Effective April 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 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

Esbriet (pirfenidone) 267mg caps, Esbriet (pirfenidone) 267mg tabs, Esbriet (pirfenidone) 801mg tabs, Jascayd (nerandomilast), Ofev (nintedanib esylate), and pirfenidone tab 534mg – These medications and their generics (if applicable) will require Quantity Limits across all formularies.

Xermelo (telotristat ethyl) 250mg tablet – This medication will require Prior Authorization (PA) review on the Essential formularies (PA was previously added to Enhanced and Value Prior Authorization on the Net Results formularies).

Ekterly (sebetralstat 300 mg tablet) – This product will require Step Therapy on the Enhanced formulary. Generic icatibant will be preferred.

Ruconest (C1 esterase 2100 unit) – This product will require Step Therapy on the Enhanced and Net Result formularies. Generic icatibant will be preferred.

Tryngolza (olezarsen) – This product will require Step Therapy on the Enhanced formulary. Redemplo (plozasiran) will be preferred.

Brand Premarin (conjugated estrogens) tablets – This product will require Non-Formulary review on all Essential formularies. Generic Premarin tablets will be preferred.

Veltassa (patiromer) packets – This product will require Value Prior Authorization on Net Results. Lokelma will be preferred.

Topiramate ER capsules – This product will require Value Prior Authorization on Net Results. Topiramate Sprinkle capsules will be preferred.

Saxenda (liraglutide), Klor-Con (potassium chloride) tablets, Gralise (gabapentin) tablets – These products will require Value Prior Authorization on Net Results. Their respective generic products will be preferred.

Updated requirements

Azmiro (testosterone cypionate 200mg/mL) – As it must be administered by a health care provider, this medication will no longer be covered by pharmacy benefits and may instead be covered under medical benefits.

Droxia (hydroxyurea) – This medication will require Non-Formulary review on the Essential formularies and Value Prior Authorization on the Net Results formularies. It has a generic equivalent on the formulary.

Fycompa (perampanel) suspension – This medication will require Non-Formulary review on the Essential formularies. It has a generic equivalent on the formulary.

Gleostine (lomustine) capsules – This medication will require Non-Formulary review on the Essential formularies. It has a generic equivalent on the formulary.

Ravicti (glycerol phenylbutyrate) liquid – This medication will require Non-Formulary review on the Essential formularies. It has a generic equivalent on the formulary.

Revlimid (lenalidomide) capsules – This medication will require Non-Formulary review on the Essential formularies. It has a generic equivalent on the formulary.

Stelara 45mg/0.5ml and Ustekinumab 45mg/0.5ml biosimilars – These medications and their generics (if applicable) have decreased Quantity Limits across all formularies.

Essential Q/QS Formulary Removals

• Droxia capsules
• Fycompa suspension
• Gleostine capsules
• Premarin tablets
• Ravicti liquid

Essential C Formulary Removals

• Droxia capsules
• Fycompa suspension
• Gleostine capsules
• Premarin tablets
• Ravicti Liquid
• Tetracaine 0.05% Ophthalmic Solution

Net Results – Value Prior Authorization will be required

• Brand Saxenda
• Droxia capsules
• Gralise tablets
• Klor-Con 8mEq, 10mEq tablets
• Topiramate ER 25mg, 50mg, 100mg, 200mg capsules
• Veltassa powder

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