| Medical Drug Policy Name | Revised Criteria |
|---|---|
| Fecal Microbiota, Live - jslm (Rebyota®) “Notification” (PDF) | Reformatted prior CDI episode/recurrence requirements to include a timeframe between episodes to distinguish recurrence from reinfection, added examples of standard-of-care antibiotics, and added medical record documentation requirements. Added requirement that the patient will not use Rebyota in combination with Vowst. Added specialist requirement and maximum units criterion to align with unit requirements in the dosing reference table. Policy notification given 8/3/2026 for effective date 10/1/2026. |
| Injectable Transthyretin-Mediated Amyloidosis (ATTR) Therapy “Notification” (PDF) | Original medical policy criteria issued. Consolidated “Eplontersen (Wainua)”, “Patisiran (Onpattro)”, and “Vutrisiran (Amvuttra)” medical policies into the following “Injectable Transthyretin-Mediated Amyloidosis (ATTR) Therapy” medical policy. Reformatted diagnostic criteria for hATTR-PN and ATTR-CM indications to require both genetic confirmation and confirmed amyloid deposition. Reformatted confirmation of peripheral neuropathy for hATTR-PN indication to include either abnormal electrodiagnostic studies consistent with hATTR-associated polyneuropathy or abnormal neurological examination suggestive of neuropathy, and presence of clinical manifestations of neuropathy. Added requirement that the patient does not have AL amyloidosis. Removed Tegsedi from list of TTR-directed therapies not to be used in combination due to market withdrawal. Adjusted maximum units for Wainua for clarity according to FDA labeled dosing. Policy notification given 8/3/2026 for effective date 10/1/2026. |
| Intravenous Iron Replacement Therapy “Notification” (PDF) | Added product-specific diagnoses within criteria and age limitation for Monoferric according to FDA labeled indications. For Injectafer for treatment of iron deficiency with heart failure, extended duration of approval for initial treatment to 60 days and added continuation criteria for this indication to allow for maintenance treatment, not exceeding more than 36 weeks, according to FDA labeled dosing. Adjusted Injectafer maximum units for treatment of iron deficiency with heart failure for clarity according to label. Added Site of Care medical necessity criteria. Other formatting changes made throughout policy and dosing reference table for clarity. Policy notification given 8/3/2026 for effective date 10/1/2026. |
| Repository Corticotropin “Notification” (PDF) | Added medical record documentation requirement to demonstrate the patient is experiencing an acute MS exacerbation. Other minor formatting updates made throughout policy with no change to intent. Policy notification given 8/3/2026 for effective date 10/1/2026. |
| Rituximab (Rituxan) and Rituximab Biosimilars for the Treatment of Non-Oncologic Indications “Notification” (PDF) | For SLE indication, reformatted SLE clinical diagnostic criteria to remove reference to ACR classification criteria and adjusted autoantibody positive verbiage to include different antibodies as examples. Replaced required trial and failure of a corticosteroid or immunosuppressive agent and required combination therapy with a standard immunosuppressant regimen for active SLE with the requirement that the patient has active disease while on standard therapy for SLE alone or as combination therapy. Reformatted hydroxychloroquine combination use requirement with no change to intent. For LN indication, reformatted SLE clinical diagnostic criteria to remove reference to ACR classification criteria, removed autoantibody positive requirement, adjusted LN class verbiage, reformatted hydroxychloroquine combination use requirement with no change to intent, and added requirement not to be used in combination with Lupkynis for the treatment of LN. Added Site of Care medical necessity criteria for all indications. Policy notification given 8/3/2026 for effective date 10/1/2026. |
| Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN) Targeted Therapies “Notification” (PDF) | Original medical policy criteria issued. Consolidated “Belimumab (Benlysta)”, “Anifrolumab-fnia (Saphnelo, Saphnelo Pen)”, and “Obinutuzumab (Gazyva)” medical policies into the following “Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN) Targeted Therapies” medical policy. Reformatted SLE clinical diagnostic criteria to remove reference to ACR classification criteria and adjusted autoantibody positive verbiage to include different antibodies as examples. Restructured and adjusted LN continuation criteria to require stabilization or improvement in both proteinuria and kidney function with associated laboratory parameters. Added Lupkynis and listed other examples of biologic immunomodulators not to be used in combination for the same indication within initial and continuation criteria for SLE and LN. For Benlysta and Saphnelo/Saphnelo Pen, added requirement for combination use with hydroxychloroquine within initial and continuation criteria, adjusted list of standard SLE therapy examples to include mycophenolic acid analogs, and added specialist requirement within initial and continuation criteria. For Benlysta, reformatted criteria for age and for active LN requiring standard immunosuppressive therapy, and added requirement that the patient does not have severe active CNS lupus per FDA label; for self-administration requirements within initial and continuation criteria, removed age specific references and option for patients with LN who have not yet received two IV doses to align with updated FDA label. For Benlysta subcutaneous formulations, added HCPCS codes C9399, J3490, and J3590 to dosing reference table for clarity. For Gazyva, removed autoantibody positive requirement, adjusted LN class verbiage, and reformatted hydroxychloroquine combination use requirement for consistency with no change to intent; within continuation criteria, applied general clinical benefit requirements and adjusted requirement for current treatment with a standard immunosuppressive LN therapy to current treatment with hydroxychloroquine. Policy notification given 8/3/2026 for effective date 10/1/2026. |
| Tocilizumab (Actemra) and Tocilizumab Biosimilars “Notification” (PDF) | Changed requirement for trial and failure of preferred tocilizumab biosimilar products to include Avtozma in addition to existing preferred Tyenne; adjusted non-preferred tocilizumab products to include Actemra and Tofidence. For Actemra subcutaneous formulations, added HCPCS codes C9399, J3490, and J3590 to dosing reference table for clarity. Policy notification given 8/3/2026 for effective date 10/1/2026. |
| Treatment of Thyroid Eye Disease “Notification” (PDF) | For Tepezza, added medical record documentation requirements to demonstrate that the patient has not received prior treatment with Tepezza during their lifetime or is currently receiving treatment, and will not receive more than one treatment course of 8 infusions per lifetime. Policy notification given 8/3/2026 for effective date 10/1/2026. |
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
Technical Information Privacy Policy Terms of Use Fraud & Abuse Linked Apps
© 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.