Effective July 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. Notification of the following changes were published on April 2, 2026, and May 1, 2026. 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: 

Gonadotropin Releasing Hormone Therapy policy (PDF)

Camcevi, Camcevi ETM, Eligard, Leuprolide Depot (generic), Lupron Depot Kit, Lupron Depot-Ped Kit, Lutrate Depot, and Vabrinty – We will require certain gonadotropin releasing hormone (GnRH) drugs to be rendered at alternative locations for any new or renewal authorization requests for these products. 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 Infusion (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 GnRH 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. 

Interleukin-5 Antagonists policy (PDF)

Exdensur – We are updating our interleukin-5 antagonists utilization criteria to remove Exdensur from preferred status. Cinqair, Fasenra, and Nucala will be preferred over Exdensur. 

Rituximab (Rituxan) and Rituximab Biosimilars for the Treatment of Non-Oncologic Indications policy (PDF)

Rituximab products (Rituxan, Riabni, Ruxience, Truxima) – We are updating our rituximab utilization criteria to require prior authorization for additional non-oncologic indications with specific criteria for coverage. With this change, we will continue to prefer specific biosimilar versions of rituximab. Riabni, Ruxience, and Truxima will continue to be preferred over Rituxan. 

Testosterone Cypionate (Azmiro) policy (PDF)

Azmiro – We are updating our testosterone cypionate utilization criteria to require prior authorization for Azmiro when billed under the medical benefit only. Azmiro currently requires prior authorization when billed under the pharmacy benefit only. We will also be changing to prefer testosterone cypionate (Depo-Testosterone), and Azmiro will be removed from preferred status. Note, other injectable testosterone products will continue to be available when billed under the pharmacy benefit only. 

Additionally, we will require use of a self-administered formulation of testosterone billed under the pharmacy benefit for all members requesting use of Azmiro 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 of testosterone products under the pharmacy benefit can be found on the prior review plan page by searching and selecting Testosterone Cypionate. A list of in network pharmacies can also be found on our site. Please verify all members' specific benefits and in-network specialty pharmacies. 

Therapeutic Radiopharmaceuticals in Oncology policy (PDF)

Lutathera, Pluvicto, Xofigo – We are updating our therapeutic radiopharmaceuticals utilization criteria to require prior authorization review for Xofigo with specific criteria for coverage. Additionally, review of authorization requests for these therapies will follow a similar process to how our other medical drugs are reviewed at Blue Cross NC. Providers requesting prior authorization for these medications on or after July 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 July 1. 

White Blood Cell Growth Factors policy (PDF)

Armlupeg, Ennumo, Filkri, Granix, Neulasta, Neulasta OnPro, Neupogen, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Udenyca, Udenyca Onbody, and Ziextenzo – We will require certain white blood cell growth factor drugs to be rendered at alternative locations for any new or renewal authorization requests for these products. 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 white blood cell growth factor 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. 

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 July 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 July 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.