Effective April 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:

Antiemetic injection therapy policy 

Akynzeo, Aloxi (palonosetron), Cinvanti, Emend, Focinvez, Posfrea, and Sustol – We are updating our antiemetic injection therapy utilization criteria to prefer Aloxi (palonosetron) and Emend (fosaprepitant). With this change, Akynzeo, Cinvanti, Focinvez, Posfrea, and Sustol will be non-preferred injectable antiemetic products and will continue to require prior authorization. Aloxi (palonosetron) and Emend (fosaprepitant) will have prior authorization removed. 

Preferred injectable antiemetic products (unrestricted) 

• Aloxi (palonosetron) 
• Emend (fosaprepitant) 

Non-preferred injectable antiemetic products 

• Akynzeo (fosnetupitant/palonosetron) 
• Cinvanti (aprepitant) 
• Focinvez (fosaprepitant) 
• Posfrea (palonosetron) 
• Sustol (granisetron extended release) 

Additionally, we will begin to process clinical reviews for the non-preferred injectable antiemetic 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 non-preferred injectable antiemetic product on or after April 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 April 1. 

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

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. Bildyos, Jubbonti, and Stoboclo will be preferred over Prolia and other non-preferred Prolia (denosumab) biosimilar products. Bilprevda, Osenvelt, and Wyost will be preferred over Xgeva and other non-preferred Xgeva (denosumab) biosimilar products. 

Additionally, we will require all denosumab products to be rendered at alternative locations for any new or renewal authorization requests for a denosumab product. This follows a similar process to how our other medical drugs with Place of Service restrictions are reviewed at Blue Cross NC. The policy, Place of Service for Medical Infusions (PDF), applies alternative location guidelines for medications ordered within select therapeutic categories. Blue Cross NC members’ benefits and the availability of coverage for certain provider-administered medications such as denosumab products may be limited to infusion services provided at non-hospital locations, unless the member is considered medically unstable or not clinically appropriate to receive infusions outside of a hospital setting. Blue Cross NC members considered medically stable may be required to receive certain provider-administered medications at approved locations, which include non-hospital outpatient centers, physicians’ offices, ambulatory, and home infusion. Please work with your Blue Cross NC patients if changes to their locations for care are necessary. 

Familial chylomicronemia syndrome therapy policy 

Redemplo and Tryngolza – We are updating our familial chylomicronemia syndrome therapy utilization criteria to require prior authorization for Tryngolza billed under the medical benefit. Tryngolza currently requires prior authorization when billed under the pharmacy benefit only. We will also be changing to prefer Redemplo. Tryngolza will be removed from preferred status. 

Additionally, we will require use of the self-administered formulation of Redemplo and Tryngolza billed under the pharmacy benefit for all members requesting use of Redemplo or Tryngolza 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 Redemplo – Pharmacy or Tryngolza – 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. 

Gonadotropin releasing hormone therapy policy 

Camcevi, Camcevi ETM, Eligard, Fensolvi, Leuprolide Depot (generic), Lupron Depot Kit, Lupron Depot-Ped Kit, Lutrate Depot, Supprelin LA, Trelstar, Triptodur, Vabrinty, and Zoladex – We will begin to process clinical reviews for the gonadotropin releasing hormone (GnRH) medical benefit products for oncologic uses 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 GnRH medical benefit product for oncologic use on or after April 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 April 1. 

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

Omidubicel (Omisirge) policy 

Omisirge – This medication will require prior authorization review with specific criteria for coverage. Additionally, review of authorization requests for Omisirge will follow a similar process to how our other medical drugs are reviewed at Blue Cross NC. Providers requesting prior authorization for this medication on or after April 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 April 1. 

Treatment of hereditary angioedema policy 

Firazyr, Sajazir, Ruconest – We are updating our hereditary angioedema treatment utilization criteria to prefer generic icatibant. Brands Firazyr, Sajazir, and Ruconest will be removed from preferred status. 

Berinert, Firazyr, Icatibant (generic), Ruconest, and Sajazir – We will require use of the self-administered formulations of these hereditary angioedema medications billed under the pharmacy benefit for all members requesting use of these medications billed under the medical benefit 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 Berinert – Pharmacy, Firazyr – Pharmacy, Icatibant – Pharmacy, Ruconest – Pharmacy, or Sajazir – 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. 

Updated coding-related requirements:

Cell and gene therapy policies

We will require prior authorization for the revenue codes listed below that are applicable to gene and cell therapy products. View the Notification of Drug Policy Revisions Effective April 1, 2026, Posted February 1, 2026, for more information. 

• 0891 – Special Processed Drugs-FDA Approved Cell Therapy 
• 0892 – Special Processed Drugs-FDA Approved Gene Therapy 

Self-injectable medications 

We will be updating the coverage accessibility for certain self-injectable products listed below. Since these injectable products are self-administered and do not require professional administration, these products will continue to be covered under the pharmacy benefit only, subject to the coverage restrictions under the member’s pharmacy benefit, and will no longer be covered under the medical benefit. For questions about submission of claims for self-injectable products under the medical benefit, the provider should contact the member’s pharmacy benefit manager. View more coverage details with our commercial prior authorization drug search tools. 

• J1941 – Furoscix (furosemide) for subcutaneous injection 
• J9218 – Leuprolide acetate for subcutaneous injection 

Blue Cross NC provides coverage under its medical and prescription drug benefits for medications in accordance with benefit guidelines. Certain self-administered medications are only covered under the prescription drug benefit and are excluded from Blue Cross NC’s medical benefit. Self-administered medications do not require professional administration. If 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. 

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 April 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 April 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.