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Blue Cross Blue Shield of NebraskaCommercial · Prior Auth · Pharmacy · NE · Oncology, Rheumatology, Infectious Disease +2 moreHigh impact

Medical/Pharmacy Policy Updates Effective 12/15/2026

Act
by Dec 15, 2026
Effective date
Dec 15, 2026
Identified
Oct 10, 2026

Summary

Blue Cross and Blue Shield of Nebraska (BCBSNE) is implementing a new medical policy (MPC X.242 OptimizeRX) effective 12/15/2026 that establishes step therapy requirements for multiple biologic medications. Preauthorization is now required for all nonpreferred products, and patients must demonstrate contraindication, intolerance, or failure to a preferred product before nonpreferred alternatives will be considered. This applies to both new and established patients across denosumab, infliximab, rituximab, tocilizumab, and trastuzumab drug classes.

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What to do

by Dec 15, 2026 · 5 steps
01Billing and prior authorization teams must implement step therapy requirements for all nonpreferred biologic products listed under policy MPC X.242 OptimizeRX in the billing system and prior authorization workflows.
02Configure the billing system to require preauthorization for all nonpreferred denosumab, infliximab, rituximab, tocilizumab, and trastuzumab products (HCPCS codes Q5121, Q5103, Q5104, Q5119, Q5115, Q5123, Q5135, Q5156, Q5117, Q5116, Q5113, Q5114, Q5112, Q5162, Q5136, Q5157, Q5161, Q5167, Q5171, Q5166, Q5173, Q5159, J0897, J1745, J9312, J9311, J3262, J3590, J9355, J9356).
03Update prior authorization request templates to require documentation of patient contraindication, intolerance, or prior failure to preferred products before approval of nonpreferred alternatives.
04Train front-desk, billing, and clinical staff on the new step therapy workflow for both new-start and established patients.
05Verify BCBSNE claims submission processes reflect the new preauthorization mandate to avoid claim denials.
If missed: Failure to implement preauthorization will result in claim denials for nonpreferred biologic products.

Codes mentioned

J0897J1745J9312J9311J3262J3590J9355J9356Q5121Q5103Q5104Q5119Q5115Q5123Q5135Q5156Q5117Q5116Q5113Q5114Q5112Q5162Q5136Q5157Q5161Q5167Q5171Q5166Q5173Q5159

Original notice

Medical/Pharmacy Policy Updates Effective 12/15/2026
nebraskablue.com · Always check the source before changing claims.
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Related changes

See all Blue Cross Blue Shield of Nebraska changes →
Medical/Pharmacy Policy Updates Effective 12/15/2026HighEffective Dec 15, 2026 · PharmacyOptimizeRx Medical Policy Update Effective 01/01/2027HighEffective Jan 1, 2027 · Medical PolicyOptimizeRx Medical Policy Update Effective 01/01/2027MediumEffective Jan 1, 2027 · Medical PolicyMPC February 2026MediumEffective Jun 1, 2026 · Medical PolicyBrowse every Blue Cross Blue Shield of Nebraska change in the policy list

Related policy hubs

Blue Cross Blue Shield of Nebraska policiesNE policy changesOncologyRheumatologyInfectious DiseaseHematologyPharmacyCode J0897Code J1745Code J9312Code J9311Code J3262Code J3590Code J9355Code J9356Code Q5121Code Q5103Code Q5104Code Q5119Code Q5115Code Q5123Code Q5135Code Q5156Code Q5117Code Q5116Code Q5113Code Q5114Code Q5112Code Q5162Code Q5136Code Q5157Code Q5161Code Q5167Code Q5171Code Q5166Code Q5173Code Q5159

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