Blue Cross Blue Shield - North Carolina Coverage Criteria
- Blue Cross Blue Shield - North Carolina prior authorization
- Blue Cross Blue Shield - North Carolina timely filing
- All Blue Cross Blue Shield - North Carolina policy updates
Latest Blue Cross Blue Shield - North Carolina coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Evinacumab-dgnb (Evkeeza) IV infusion — Coverage Criteria for Homozygous Familial HypercholesterolemiaDefines medical necessity, site-of-care, authorization, and dosing/units for evinacumab-dgnb (Evkeeza) IV infusion for patients aged ≥1 year with homozygous familial hypercholesterolemia (HoFH); applies to Blue Cross NC membership and providers requesting coverage.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-15Amniotic Membrane and Amniotic Fluid Injections for Ophthalmic IndicationsDefines coverage and medical necessity criteria for human amniotic membrane grafts and states investigational status for injections of amniotic fluid and particulated amniotic membrane for ophthalmic indications; applies to BCBS North Carolina providers and members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-15Microprocessor-Controlled Prostheses for the Lower LimbDefines BCBSNC coverage, medical necessity criteria, and coding guidance for microprocessor-controlled prosthetic knees and ankle-foot devices for members requiring lower-limb prostheses.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Certolizumab pegol (Cimzia) — Coverage CriteriaDefines medical necessity, site-of-care, dosing limits, and documentation requirements for certolizumab pegol (Cimzia) subcutaneous injection for patients treated for labeled indications under Blue Cross NC.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Gonadotropin Releasing Hormone (GnRH) Therapy NotificationDefines coverage, medical necessity criteria, restricted products, dosing/HCPCS units, duration limits, and site-of-care considerations for GnRH (leuprolide, triptorelin, histrelin, goserelin) therapies for Blue Cross Blue Shield North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Guselkumab (Tremfya) — coverage criteria for IV and SC administrationDefines medical necessity, site-of-care, dosing limits, and documentation requirements for guselkumab (Tremfya) IV and SC administration across FDA-approved indications (psoriasis, psoriatic arthritis, ulcerative colitis, Crohn's disease); affects prescribers, infusion centers, and prior authorization reviewers.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Interleukin-5 Antagonists (benralizumab, depemokimab, mepolizumab, reslizumab) — Notification / Coverage CriteriaMedical necessity and notification criteria for administration and coverage of IL-5 antagonist biologics for eosinophilic asthma and other eosinophilic conditions for Blue Cross Blue Shield North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Mirikizumab-mrkz (Omvoh) — Intravenous Infusion (Notification) Coverage CriteriaDefines medical necessity and prior authorization requirements for intravenous mirikizumab (Omvoh) for adults with moderately to severely active Crohn's disease or ulcerative colitis for Blue Cross Blue Shield North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Omalizumab (Xolair) subcutaneous injection — Coverage CriteriaDefines medical necessity, initial and continuation coverage criteria, site-of-care rules, dosing limits, and documentation requirements for omalizumab (Xolair) administered by a healthcare professional for Blue Cross NC members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Rituximab (Rituxan) and Rituximab Biosimilars for the Treatment of Non-Oncologic IndicationsNotification policy describing medical necessity criteria and product preferences for intravenous rituximab (Rituxan) and specified biosimilars for a range of non-oncologic autoimmune, hematologic, renal, neurologic, and pediatric indications for Blue Cross NC members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Tezepelumab-ekko (Tezspire) — Notification (coverage criteria)Defines medical necessity, initial and continuation authorization, site-of-care criteria, dosing limits, and documentation requirements for tezepelumab-ekko (Tezspire) for patients ≥12 years with severe asthma or CRSwNP; applies to providers requesting administration by a healthcare professional. Affects Blue Cross NC members and treating clinicians.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Therapeutic Radiopharmaceuticals in Oncology (Lutathera, Pluvicto, Xofigo) Coverage CriteriaDefines medical necessity criteria, dosing limits, and documentation requirements for lutetium Lu 177 dotatate (Lutathera), lutetium Lu 177 vipivotide tetraxetan (Pluvicto), and radium Ra 223 dichloride (Xofigo) for Blue Cross NC members; applies to providers requesting coverage for these agents.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Tocilizumab (Actemra) and Tocilizumab Biosimilars coverageMedical policy governing prior authorization and medical necessity criteria for tocilizumab (Actemra) and specified biosimilars for outpatient/inpatient use for BCBS North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Artificial Pancreas Device SystemsThis policy governs medical necessity coverage for automated insulin delivery systems (artificial pancreas/closed-loop/hybrid closed-loop systems and sensor-augmented pumps with low glucose suspend features) for BCBSNC members with insulin-dependent diabetes.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Narsoplimab-wuug (Yartemlea) — Coverage Criteria for TA-TMACovers medical necessity and authorization criteria for narsoplimab-wuug (Yartemlea) IV infusion to treat hematopoietic stem cell transplant–associated thrombotic microangiopathy (TA-TMA) in patients aged 2 years and older; applies to Blue Cross Blue Shield - North Carolina.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Afamitresgene autoleucel (Tecelra) — Coverage CriteriaDefines medical necessity criteria, dosing, and administrative requirements for coverage of afamitresgene autoleucel (Tecelra) for adults with unresectable or metastatic synovial sarcoma under Blue Cross NC.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Allogeneic Processed Thymus Tissue (Rethymic) — Coverage CriteriaPolicy governs coverage and medical necessity criteria for use of allogeneic processed thymus tissue (Rethymic) for immune reconstitution in pediatric congenital athymia patients, and applies to providers submitting claims to Blue Cross NC.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Atidarsagene autotemcel (Lenmeldy) — coverage criteria for metachromatic leukodystrophyMedical policy governing coverage criteria, dosing, and administrative requirements for atidarsagene autotemcel (Lenmeldy) intravenous infusion for children with specific subtypes of metachromatic leukodystrophy (MLD). Affects pediatric patients and providers requesting coverage from Blue Cross NC.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Beremagene geperpavec-svdt (Vyjuvek) topical gene therapy for dystrophic epidermolysis bullosa — Coverage CriteriaPolicy governs medical necessity criteria, dosing, site-of-care, and distribution restrictions for beremagene geperpavec-svdt (Vyjuvek) when used to treat wounds in patients with dystrophic epidermolysis bullosa due to COL7A1 mutations; applies to Blue Cross NC members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Betibeglogene autotemcel (Zynteglo) — Coverage Criteria for Transfusion-Dependent Beta-ThalassemiaDefines medical necessity, eligibility criteria, and authorization details for coverage of betibeglogene autotemcel (Zynteglo) intravenous infusion for members with transfusion-dependent beta-thalassemia in North Carolina.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01CAR T-cell therapy (listed products) — coverage criteriaThis policy governs medical necessity coverage criteria for specific autologous CAR T-cell therapies for hematologic malignancies for Blue Cross Blue Shield of North Carolina members and outlines required documentation and dosing/administration limits.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01CAR-T Therapy "Notification" (PDF) Opens in a New Tab.Defines notification/coverage criteria and documentation requirements for multiple FDA-approved autologous CAR-T cellular therapies (listed products) for specified hematologic malignancies, dosing limits, lymphodepletion regimens, and one-course-per-lifetime duration. Includes HCPCS/Q-codes, related CPT and revenue code mapping, and distribution note.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Donislecel-jujn (Lantidra) — Hepatic Portal Vein Islet Transplantation Coverage CriteriaDefines medical necessity, approval criteria, and utilization limits for donislecel-jujn (Lantidra) hepatic portal vein islet transplantation for adults with type 1 diabetes with recurrent severe hypoglycemia; applies to Blue Cross NC members and providers.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Eladocagene exuparvovec-tneq (Kebilidi) intraputaminal infusion coverage criteriaDefines medical necessity, coverage limitations, and documentation requirements for eladocagene exuparvovec-tneq (Kebilidi) intraputaminal infusion for treatment of AADC deficiency for Blue Cross NC members.All Blue Cross Blue Shield - North Carolina updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Elivaldogene autotemcel (Skysona) — Coverage Criteria for Early, Active Cerebral Adrenoleukodystrophy (CALD)Defines medical necessity criteria, documentation, and coding for coverage of intravenous elivaldogene autotemcel (Skysona) for boys 4–17 years with early, active CALD when no HLA‑matched donor is available; applies to Blue Cross NC members and providers.All Blue Cross Blue Shield - North Carolina updates
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Tool Description
Search Blue Cross Blue Shield - North Carolina coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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