Commercial Medical Drug Policy Utilization Management Updates Effective October 1, 2026

Effective October 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:

Intravenous Iron Replacement Therapy policy

Injectafer and Monoferric – We will require certain intravenous (IV) iron replacement medications 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 IV iron replacement 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.

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

Rituximab products (Rituxan, Riabni, Ruxience, Truxima) – We will require certain rituximab medications 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 rituximab 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.

Tocilizumab (Actemra) and Tocilizumab Biosimilars policy

Tocilizumab products (Actemra, Avtozma, Tofidence, Tyenne) – We are updating our preferred tocilizumab biosimilar products to include Avtozma and Tyenne (previously Tyenne). With this change, Avtozma and Tyenne will be preferred over Actemra and Tofidence.

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 October 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 October 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.