| Medical Drug Policy Name | Revised Criteria |
|---|---|
| Rituximab (Rituxan®) and Rituximab Biosimilars for the Treatment of Non-Oncologic Indications “Notification” | Added the following non-oncologic indications to policy with associated criteria and required trial and failure of preferred rituximab biosimilar products (i.e., Riabni, Ruxience, and Truxima): granulomatosis with polyangiitis (GPA) (Wegener’s granulomatosis) and microscopic polyangiitis (MPA) [both ANCA-associated vasculitides]; moderate to severe pemphigus vulgaris (PV); autoimmune hemolytic anemia (AIHA), including cold agglutinin disease; immune (idiopathic) thrombocytopenia (ITP, Evans syndrome), chronic; thrombotic thrombocytopenic purpura (TTP); multiple sclerosis (MS), relapsing forms; neuromyelitis optica spectrum disorder (NMOSD); immunoglobulin G4-related disease (IgG4-RD); generalized myasthenia gravis (gMG), refractory; systemic lupus erythematosus (SLE); lupus nephritis (LN); idiopathic (primary) membranous nephropathy; pediatric idiopathic nephrotic syndrome; Wiskott-Aldrich syndrome; antisynthetase syndrome-related interstitial lung disease. Added applicable dosing and associated maximum units within dosing reference table for each indication. Changed policy name to “Rituximab (Rituxan) and Rituximab Biosimilars for the Treatment of Non-Oncologic Indications” from “Rituximab for the Treatment of Rheumatoid Arthritis”. Policy notification given 4/2/2026 for effective date 7/1/2026. |
| Testosterone Cypionate (Azmiro®) “Notification” | Original medical policy criteria issued. Added to initial and continuation criteria the requirement for use of a self-administered formulation of testosterone unless certain criteria are met. Added to initial and continuation criteria the requirement for trial and failure of Depo-Testosterone (testosterone cypionate). Added maximum units. Policy notification given 4/2/2026 for effective date 7/1/2026. |
| Therapeutic Radiopharmaceuticals in Oncology “Notification” | Added Xofigo (radium Ra 223 dichloride) and associated criteria to policy for treatment of castration-resistant prostate cancer in patients with symptomatic bone metastases and no known visceral metastatic disease. For Lutathera, extended age to 12 years and older for treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs) according to FDA label. For Pluvicto, added requirement that the patient has had a bilateral orchiectomy or will be using the requested agent in combination with a GnRH agonist or degarelix. Added requirement to be prescribed by or in consultation with a specialist; added maximum units; medical policy formatting change. Policy notification given 4/2/2026 for effective date 7/1/2026. |
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2026 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.