CurrentBlue Cross Blue Shield - IowaPolicy 05.05.26

Wellmark Blue Cross and Blue Shield Bimzelx Drug Policy

Defines prior authorization criteria, required documentation, prescriber specialties, quantity limits, dosing constraints, and renewal criteria for Bimzelx (bimekizumab-bkzx) across FDA-approved indications (plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, hidradenitis suppurativa) for Wellmark Blue Cross and Blue Shield.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyWellmark Blue Cross and Blue Shield Bimzelx Drug Policy

Policy CodePolicy 05.05.26

Change TypeRevised

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmission of required documentation (chart notes, medication history, BSA, symptom improvement, prior therapy failures or contraindications) is necessary to initiate prior authorization review and to demonstrate criteria are met.

SourceLink

POLICY UPDATE CHANGES

Policy reviewed and revised in October 2025 with current effective date January 1, 2026.

5FDA-approved indications listed

12 monthsTypical authorization duration

17 weeksPlaque psoriasis initiation period

90 daysHS antibiotic trial requirement

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Coverage Summary

Coverage stance: covered_with_criteria for Bimzelx (bimekizumab-bkzx) across its FDA‑approved indications: plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non‑radiographic axial spondyloarthritis, and hidradenitis suppurativa. The policy applies prior authorization with specified documentation requirements, prescriber specialty requirements for initial approvals, and dosing/quantity limits. Typical quantity limits and dosing constraints are defined by indication (see quantity limits for initiation/maintenance dosing). Authorization is contingent on meeting the plan’s Preferred Drug Plan Design (use of preferred products) and condition‑specific clinical criteria. Renewal/continuation authorizations are generally for 12 months. The policy requires that the member try two preferred products before using a non‑preferred agent unless there is a continuity‑of‑care exception, clinical reasons to avoid the preferred options, or only one preferred product exists for the indication.

Quick facts / thresholds

FDA‑approved indications count5

Typical authorization duration12 months

Plaque psoriasis initiation period (quantity limit interval)17 weeks

Hidradenitis suppurativa antibiotic trial90 days

TB screening window (negative test)Within 12 months prior to initiation

Policy effective date (current)January 1, 2026

Policy intentSteer utilization to preferred, cost‑effective medications and ensure appropriate patient selection per labeling/guidelines

Initial Therapy Criteria

General Requirements

ALL of the following

FDA‑approved or compendia indication: Requested use is for an FDA‑approved indication (Plaque psoriasis, PsA, nr-axSpA, AS, HS) or compendia-supported indication as applicable
Non-Formulary Exception requires FDA-approved or compendia-supported indication
No concomitant biologic/targeted synthetic: Member cannot use the requested medication concomitantly with any other biologic or targeted synthetic drug for the same indication
TB screening: Documented negative TB test within 12 months for biologic/ts-naïve persons; if positive, exclude active TB and treat latent TB before initiationNegative TB test within 12 months

Continuation Therapy / Renewal Criteria

Continuation / Authorization Renewal Criteria

Authorization of 12 months may be granted when positive clinical response is documented:

Plaque psoriasis response: Plaque psoriasis: Reduction in BSA affected or improvement in signs/symptoms from baseline
Psoriatic arthritis response: Psoriatic arthritis: Improvement in any of: number of swollen joints, number of tender joints, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, CRP
AS and nr-axSpA response: AS and nr-axSpA: Improvement in any of: functional status, total spinal pain, inflammation (e.g., morning stiffness), swollen joints, tender joints, CRP

Provider Actions

Prior Authorization

Prior authorization required

Submission of required documentation (chart notes, medication history, BSA, symptom improvement, prior therapy failures or contraindications) is necessary to initiate prior authorization review and to demonstrate that the member meets policy criteria. Providers should include relevant medical records to allow PA review to begin.

Documentation Required

Required documentation specifics

Provide indication-specific documentation as follows to support initial and continuation requests.

PsO initial requests: chart notes documenting body surface area (BSA) affected and the specific affected areas.
PsO continuation requests: chart notes documenting decreased BSA and/or improvement in signs and symptoms.
AS / nr-axSpA / PsA / HS initial requests: chart notes, medical records, or claims history documenting prior medication trials and responses (or clinical reasons to avoid therapies).

Applicable Codes

Procedures and Reporting Codesmixed

No codes listed

Clinical Evidence & References

Key evidence and references include the product labeling: Bimzelx [package insert], November 2024, phase 3 clinical trials such as BE READY and BE VIVID (and other phase 3 trials), and relevant clinical guidelines and publications cited in the policy (Lancet, New England Journal of Medicine, AAD‑NPF guidelines and HS guidelines).

5FDA‑approved indications listed

12Typical authorization duration (months)

17Plaque psoriasis initiation period (weeks)

90HS antibiotic trial requirement (days)

Background

Background: The policy aims to ensure appropriate selection of patients for Bimzelx using product labeling, clinical guidelines, and clinical studies while steering utilization to preferred, cost‑effective medications. It implements prior authorization, prescriber specialty requirements, quantity limits and dosing constraints, and renewal criteria to support appropriate use. Consistent with the Preferred Drug Plan Design, the policy requires use of two preferred products before approval of a non‑preferred product unless there are documented clinical circumstances that exclude preferred options or the member is continuing effective therapy with the non‑preferred agent. Definition — Preferred products: Adalimumab‑aacf, Enbrel, Cosentyx, Otezla, Rinvoq, Simponi, Skyrizi, Otulfi (ustekinumab‑aauz), Tremfya, and Xeljanz/Xeljanz XR — products designated as preferred options for indications.

Revision History

2024-04-07original_effective

Original effective date (policy first effective).

2025-10-01reviewed_revised

Policy reviewed and revised in October 2025.

2026-01-01current_effectiveLatest

Current effective date for the revised policy.