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Blue Cross & Blue Shield of MississippiCommercial · Coverage · Medical Policy · MS · Rheumatology, Hematology, Nephrology +2 moreMedium impact

State and School Employees' Health Insurance Plan - Rituximab Non-Oncology

Effective date
Not stated in the notice
Identified
Jun 20, 2026

Summary

Riabni (rituximab-arrx), Ruxience (rituximab-pvvr), and Truxima (rituximab-abbs) may be considered medically necessary for listed non-oncologic indications when the criteria for that condition are met, including rheumatoid arthritis, ANCA-associated vasculitis, pemphigus, autoimmune hemolytic anemia, chronic graft versus host disease, immune thrombocytopenia, neuromyelitis optica spectrum disorder, systemic lupus erythematosus, thrombotic thrombocytopenic purpura, multiple sclerosis, membranous nephropathy, and refractory myasthenia gravis. The 11/01/2026 update added Riabni as medically necessary and added HCPCS code Q5123. The 06/15/2026 update revised the criteria for the listed conditions and added a prescriber and dosage requirement.

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What to do

Action · 9 steps
01Before billing Riabni (Q5123), Ruxience (Q5119), or Truxima (Q5115) for a non-oncologic indication, confirm the member meets the criteria for that diagnosis, and document it in the chart.
02Examples include the conventional-agent history for rheumatoid arthritis, the prior therapy and documented response for the other conditions, and hepatitis B screening with HBsAg and anti-HBc before treatment.
03If the screening is positive, hepatitis B therapy must have begun.
04The member must not be treated with another immunomodulatory agent such as a TNF inhibitor, JAK inhibitor, or IL inhibitor.
05The prescriber must be a specialist or have consulted one for the diagnosis, and the dose must be within program quantity limits or compendia-supported dosing.
06Initial approval lasts up to 12 months, and renewal requires documented clinical response.
07Stop billing Rituxan (J9312) for these members, because Rituxan is considered not medically necessary on all Blue Cross & Blue Shield of Mississippi formularies as other formulary alternatives are available.
08Rituxan Hycela is considered investigational for non-oncologic diagnoses.
09Services related to delivery or administration of a medication determined not medically necessary are also not medically necessary.

Codes mentioned

C9399Q5115Q5119Q5123G36.0M05.00M06.09M06.80M06.9M06.0AM31.30M31.31M31.7J9312

Original notice

State and School Employees' Health Insurance Plan - Rituximab Non-Oncology
bcbsms.com · Always check the source before changing claims.
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Related changes

See all Blue Cross & Blue Shield of Mississippi changes →
State and School Employees' Health Insurance Plan - Anti-Rheumatic BiologicalsHighNo effective date · Medical PolicyState and School Employees' Health Insurance Plan - Immune ThrombocytopeniaHighNo effective date · Medical PolicyImmune ThrombocytopeniaHighNo effective date · Medical PolicyState and School Employees' Health Insurance Plan - Biosimilar MedicationsHighEffective Jan 1, 2027 · Medical PolicyBrowse every Blue Cross & Blue Shield of Mississippi change in the policy list

Related policy hubs

Blue Cross & Blue Shield of Mississippi policiesMS policy changesRheumatologyHematologyNephrologyNeurologyDermatologyCode C9399Code Q5115Code Q5119Code Q5123Code G36.0Code M05.00Code M06.09Code M06.80Code M06.9Code M06.0ACode M31.30Code M31.31Code M31.7Code J9312

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