Effective January 1, 2026, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have changes to our medical drug utilization management (UM) requirements. Below is a high-level summary of the major changes occurring. View more coverage details with our Commercial prior authorization drug search tools, and a complete summary of upcoming policy changes.

Blue Cross NC is making these changes for several reasons, including:

• Taking steps to help control the cost of medical drugs and improve access to treatment for our members. Many of the changes we are making will help us continue to offer sustainable health plans for our members over the long term.
• Implementing ongoing programs, such as utilization 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. Members can use our find care page for more information about medical drug coverage on our website.

Our Medical UM requirements apply to all commercial members with medical benefit coverage through Blue Cross NC. These changes do not affect State Health Plan, Federal Employee Program, or Medicare members.

UPDATED REQUIREMENTS:

Complement C5 Inhibitors policy

Eculizumab products (Soliris, Bkemv, Epysqli) – We are updating our eculizumab utilization criteria to prefer Epysqli. Soliris and Bkemv will be removed from preferred status.

Denosumab (Prolia, Xgeva) and Denosumab Biosimilars policy

Denosumab products (Prolia, Xgeva, non-preferred denosumab biosimilar products) – We are updating our denosumab utilization criteria to prefer specific biosimilar versions of denosumab. Jubbonti and Stoboclo will be preferred over Prolia and other non-preferred Prolia (denosumab) biosimilar products. Wyost and Osenvelt will be preferred over Xgeva and other non-preferred Xgeva (denosumab) biosimilar products.

To ensure a smooth transition, members with a current prior authorization approval for Prolia, Xgeva, or a non-preferred denosumab biosimilar product may transition to a preferred product (Jubbonti and Stoboclo or Wyost and Osenvelt) on January 1, 2026, without requirement of an additional prior authorization at that time. Initial Jubbonti and Stobocolo or Wyost and Osenvelt prior authorizations will be active through the original prior authorization approval date of the non-preferred denosumab product. An additional prior authorization will be required after the effective change date to continue therapy with a non-preferred denosumab product.

Requests for continuation of a non-preferred denosumab product will not be able to be reviewed until after January 1, 2026.

Additionally, we will begin to process clinical reviews for all denosumab products in-house instead of through Carelon. This follows a similar process to how our other medical drugs are reviewed at Blue Cross NC. Providers requesting prior authorization for a denosumab product on or after January 1, 2026, for an applicable Commercial member will need to submit the request through MHK (accessed via Blue e) instead of through the Carelon portal. No action is needed prior to January 1.

Carelon will continue to conduct clinical reviews for all other drugs in the Carelon medical oncology program.

Neonatal Fc Receptor (FcRn) Blockers policy

Vyvgart and Vyvgart Hytrulo – We will require use of the self-administered formulation of Vyvgart Hytrulo billed under the pharmacy benefit for all members requesting use of Vyvgart or Vyvgart Hytrulo medical benefit products who can use a self-injectable or have a caregiver that is able to administer.

If the member/caregiver can self-administer but the provider would like to continue to administer the medication in the health care setting for other reasons, the medication would need to be obtained from an in-network specialty pharmacy provider. The member would then need to take the medication to the provider’s office, or the specialty pharmacy can have the medication shipped directly to their office. The provider will be able to bill for the administration of the drug but not for the drug itself.

The prior authorization criteria for coverage under the pharmacy benefit can be found on the prior review plan page by searching and selecting Vyvgart Hytrulo - Pharmacy. A list of in network pharmacies can also be found on our site. Please verify all members' specific benefits and in-network specialty pharmacies.

Imaavy – We are updating our Imaavy utilization criteria to prefer Vyvgart, Vyvgart Hytrulo, Rystiggo, or Ultomiris for certain adult members prior to the approval of Imaavy. Imaavy will be removed from preferred status.

Preferred Injectable Oncology Program policy

Rituximab products (Rituxan, Rituxan Hycela, Riabni, Ruxience, Truxima) – We are updating our preferred rituximab biosimilar products to include Riabni, Ruxience, and Truxima (previously Ruxience and Truxima). With this change, Riabni will have prior authorization removed for oncologic indications. Please note that these rituximab biosimilar products may still require review for non-oncology related indications. Please refer to our Commercial prior authorization drug search tools page for more information.

Preferred Rituximab Containing Agent(s) (Unrestricted for oncologic indications)

• Riabni (rituximab-arrx)*
• Ruxience (rituximab-pvvr)*
• Truxima (rituximab-abbs)*

Non-Preferred Rituximab Containing Agent(s)

• Rituxan (rituximab)
• Rituxan Hycela (rituximab and hyaluronidase)

*Indicated products may still require review for non-oncology related indications. Please refer to our Commercial prior authorization drug search tools page for more information.

Trastuzumab products (Kanjinti, Ogivri, Ontruzant, Trazimera, non-preferred trastuzumab products) – We are updating our preferred trastuzumab biosimilar products to include Ogivri, Ontruzant, and Trazimera (previously Kanjinti and Trazimera). With this change, Kanjinti will change to a non-preferred trastuzumab biosimilar product and will have prior authorization added, and Ogivri and Ontruzant will have prior authorization removed.

Preferred Trastuzumab Containing Agent(s) (Unrestricted)

• Ogivri (trastuzumab-dkst)
• Ontruzant (trastuzumab-dttb)
• Trazimera (trastuzumab-qyyp)

Non-Preferred Trastuzumab Containing Agent(s)

• Herceptin (trastuzumab)
• Hercessi (trastuzumab-strf)
• Herzuma (trastuzumab-pkrb)
• Kanjinti (trastuzumab-anns)
• Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

Rituximab for the Treatment of Rheumatoid Arthritis policy

Rituximab products (Rituxan, Riabni, Ruxience, Truxima) – We are updating our preferred rituximab biosimilar products to include Riabni, Ruxience, and Truxima (previously Ruxience and Truxima). All rituximab products will still require prior authorization for the treatment of rheumatoid arthritis.

Preferred Rituximab Containing Agent(s)

• Riabni (rituximab-arrx)*
• Ruxience (rituximab-pvvr)*
• Truxima (rituximab-abbs)*

Non-Preferred Rituximab Containing Agent(s)

• Rituxan (rituximab)

*Indicated products may still require review for non-oncology related indications. Please refer to our Commercial prior authorization drug search tools page for more information.

White Blood Cell Growth Factors policy

Pegfilgrastim products (Fulphila, Fylnetra, Nyvepria, non-preferred long-acting/pegfilgrastim products) – We are updating our preferred pegfilgrastim biosimilar products to include Fulphila and Fylnetra (previously Fulphila and Nyvepria). With this change, Nyvepria will change to a non-preferred trastuzumab biosimilar product and will have prior authorization added, and Fylnetra will have prior authorization removed.

Preferred Pegfilgrastim Products (Unrestricted)

• Fulphila (pegfilgrastim-jmdb)
• Fylnetra (pegfilgrastim-pbbk)

Non-Preferred Long-Acting/Pegfilgrastim Products 

• Neulasta, Neulasta OnPro (pegfilgrastim)
• Nyvepria (pegfilgrastim-apgf)
• Stimufend (pegfilgrastim-fpgk)
• Udenyca, Udenyca Onbody (pegfilgrastim-cbqv)
• Ziextenzo (pegfilgrastim-bmez)
• Rolvedon (eflapegrastim-xnst)
• Ryzneuta (efbemalenograstim alfa-vuxw)

Actions required due to these changes

Providers with members on impacted drugs should utilize the preferred products before using non-preferred products. Any members who are currently using a non-preferred drug should be moved to our preferred products as soon as possible.

Providers requesting prior authorization for a non-preferred product on or after January 1, 2026, for an applicable Commercial member will need to submit the request through MHK (accessed via Blue e). No action is needed prior to January 1, 2026.

Please submit all requests through Blue e for fastest processing times.

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