ModifiedBlue Cross Blue Shield - MassachusettsPolicy 040

Journavx_Coverage_Criteria

Pharmacy benefit coverage policy for Journavx (suzetrigine) for BCBSMA commercial members, defining prior authorization, age and indication criteria, supply/quantity limits, and exception/individual consideration process.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyJournavx_Coverage_Criteria

Policy CodePolicy 040

Change TypeRevision (10/15/2025)Initial creation (08/2025)

Effective Date

Next Review Date

Key ActionPrior authorization required for additional courses beyond one initial 14-day supply (29 tablets) in a 60-day period; if criteria met, authorization granted for 30 days with quantity limit of 29 tablets/14 days.

SourceLink

POLICY UPDATE CHANGES

Revision of policy; updating JournavX criteria on 10/15/2025.

Creation of medical policy 040 and added Journavx in 08/2025.

1Initial supply allowed without PA

18+Minimum age for prior authorization coverage

29Maximum quantity per 14 days

30 daysAuthorization duration if approved

Coverage Summary

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Pharmacy benefit coverage policy for Journavx (suzetrigine) for BCBSMA commercial members: covered with criteria (prior authorization required for courses beyond the initial supply) that define age and indication requirements, supply/quantity limits, and the exception/individual consideration process.

Surface thresholds and quick facts

Initial supply limitOne 14-day supply (29 tablets) per 60-day period

Post-authorization quantity limit29 tablets per 14 days

Approval duration (if authorized)30 days

Minimum age for coverage criteria18 years or older