Effective April 6, 2026, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will expand Medicare Part B step therapy and prior authorization requirements for select Part B medications. Prior authorization will address medical necessity, while step therapy focuses on the use of safe, lower-cost alternatives.

Please note:

• Any prior requirements already in place for these medications will continue to apply
• Step therapy program requirements will only apply to members new to these medications; current users will not be impacted

Medications affected

The following Medicare Part B medications* will require prior authorization or step therapy beginning April 6, 2026:

*This list may not be comprehensive.

Beginning April 6, 2026, step therapy requirements will apply to members new to Xgeva and Prolia (HCPCS code: J0897). These medications are being specifically identified due to high utilization. Members currently using these medications will not be impacted.

View Medicare Part B step therapy and prior authorizations for more information.

Provider action required

For dates of service on or after April 6, 2026, providers must submit required clinical information to Blue Cross NC when prescribing impacted medications.

For faster service, providers can submit requests to Blue Cross NC through our free online prior authorization tools:

• Medical drug requests should be submitted electronically only through CoverMyMeds^™ (CMM)
• Pharmacy drug requests can be submitted through your preferred method: CMM or MHK, accessed through Blue e^℠

If you do not have online access, you can submit requests via fax or phone to the numbers listed at the top of the drug-specific fax form.

Important billing and coverage reminders

Please be aware that if prior plan approval of these medications is not given by Blue Cross NC, the service(s) may not be covered under the member’s Medicare Advantage plan, and the provider may be responsible for the entire cost of the drug and associated service(s). Providers cannot bill members for services when prior plan approval is required but was not obtained by the provider before services were rendered.

Additionally, if the member changes Blue Cross NC Medicare Advantage plans, you may need to certify they have met our medical necessity criteria under the new policy for the medication(s) in question.

Additional resources

Providers can find the newest drug list, criteria, and more information about our utilization programs at the following links:

• Medicare Part B prior authorization and step therapy drug codes
• Medicare prescription drug coverage details
• Prior plan approval

You can also find specific criteria and fax forms on Blue e or through CMM.

Questions?

Please call our Provider Blue Medicare line at 888-296-9790 for assistance.