Currentblue cross blue shield - michiganPolicy Y0074_Grp26JulHVEnhPAST_C

Acitretin prior authorization and coverage summary

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This document governs prior authorization and step therapy requirements for the drug acitretin (and lists related formulary drugs) for Blue Cross Blue Shield of Michigan Medicare Plus Blue Group PPO and Prescription Blue Group PDP members.

Policy Summary

Payerblue cross blue shield - michigan

PolicyAcitretin prior authorization and coverage summary

Policy CodePolicy Y0074_Grp26JulHVEnhPAST_C

Change TypeNo material change

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateJul 1, 2026

Key ActionRequest prior authorization via the pharmacy help desk and provide required clinical documentation to support coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredPA required

Not requiredPrerequisite therapy

1 YearCoverage duration

Medicare+ & PDPPlans covered

20+Products listed

Coverage Criteria and Product Summaries

Initial Therapy / General Coverage Parameters

Covered when ALL of the following are met

Acitretin coverage criteria: Agent: Acitretin; Indications: All medically-accepted indications; Coverage Duration: One Year; Prerequisite Therapy: Criteria DOES NOT require use of a prerequisite Part D drug.

No age, prescriber, exclusion, or required medical information specified in this excerpt.

Product PA summary

Products listed with brief PA attributes (examples shown); detailed medical necessity criteria are not included in this section.

General product PA attributes: Each listed product entry includes indication scope (often 'All Medically-accepted Indications'), whether off-label uses are applicable, exclusion criteria if present, any required medical information, age/prescriber restrictions if noted, coverage duration, other criteria (e.g., required trials), and whether prerequisite Part D drugs are required.

Detailed stepwise clinical criteria not provided in this section.

General product PA coverage

Covered when product-specific PA criteria are met; many entries state 'All medically-accepted indications' with PA documentation and duration requirements.

General PA coverage: Product is covered for all medically-accepted indications when PA criteria and required documentation are provided; many products have a 1 year coverage duration.

See individual product notes for exclusions and prerequisite therapy requirements.

Cosentyx (secukinumab) coverage

Cosentyx specific coverage conditions

Cosentyx indication-specific requirements: Coverage requires diagnosis-specific criteria per indication (e.g., active psoriatic arthritis; chronic moderate to severe plaque psoriasis; ankylosing spondylitis requires trial of one NSAID; non-radiographic axial spondyloarthritis requires objective signs of inflammation and trial of one NSAID; enthesitis-related arthritis requires trial of one NSAID; hidradenitis suppurativa requires diagnosis of moderate to severe HS).

Cosentyx cannot be used in combination with another biologic or targeted DMARD for the same condition; reauthorization requires documentation of positive clinical response.

Copiktra coverage

Copiktra coverage for relapsed/refractory CLL

Copiktra prerequisites: Coverage for relapsed or refractory chronic lymphocytic leukemia (CLL) requires documentation of prior therapies; policy indicates requirement of at least two prior therapies.

Prerequisite therapy required as stated in product entry.

Cystaran - Indications and Duration

Cystaran

Cystaran coverage: Covered for all medically-accepted indications; Coverage Duration: One Year; Prerequisite Therapy: Criteria DOES NOT require use of a prerequisite Part D drug.

No additional required medical information specified in this excerpt.

Dalfampridine - Indications and Exclusion

Dalfampridine ER

Dalfampridine coverage: Covered for medically-accepted indications with requirement of documentation of a baseline Timed 25‑Foot Walk (T25FW) test prior to initiation; excluded for use if the patient is wheelchair-bound or becomes wheelchair-bound.

No prerequisite Part D drug required.

Doptelet - Indications

Doptelet

Doptelet coverage: Covered for medically-accepted indications; coverage for chronic immune thrombocytopenia requires a trial of a previous therapy as specified; Prerequisite Therapy: Criteria DOES NOT require use of a prerequisite Part D drug.

Coverage duration and other specifics per product entry.

Dupixent - Indications and Reauthorization

Dupixent

Dupixent coverage: Covered for multiple FDA-labeled indications with indication-specific criteria including age/weight thresholds, required prior therapy trials (e.g., high‑potency topical corticosteroid, tacrolimus, pimecrolimus, cyclosporine, azathioprine, mycophenolate for AD), eosinophil count thresholds for some asthma/COPD indications, prohibition on combination use with another biologic/targeted DMARD for the same condition, and reauthorization requiring documentation of positive clinical response.Eosinophil >=150 cells/µL for EA; COPD >=300 cells/µL

Coverage Duration: 1 Year; Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug.

Ebglyss - Indications and Limits

Ebglyss

Ebglyss coverage: Covered for medically-accepted indications; cannot be used in combination with another biologic or targeted DMARD for the same condition; patient must weigh at least 40 kilograms and be at least 12 years of age; coverage duration 1 year; Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug.Minimum weight >= 40 kg; Minimum age >= 12 years

Reauthorization requires documentation of positive clinical response.

Product-specific PA summary (examples)

Product-specific PA criteria examples from this section (partial list):

Atopic dermatitis (AD) coverage requirements (example): Coverage for AD for patients 12 years and older requires diagnosis of moderate to severe AD and trial and treatment failure of one of: high-potency topical corticosteroid, tacrolimus, pimecrolimus, cyclosporine, azathioprine, or mycophenolate mofetil.age >= 12 years

Reauthorization requires documentation of positive clinical response.

Enbrel indication-specific criteria

Rheumatologic indications (Enbrel example):

RA initial requirement: Coverage for rheumatoid arthritis requires diagnosis of moderately to severely active RA and trial of one DMARD (e.g., methotrexate, leflunomide, sulfasalazine).

Reauthorization requires documentation of positive clinical response.

Ankylosing spondylitis requirement: Coverage for ankylosing spondylitis requires diagnosis of active AS and trial of one NSAID (e.g., diclofenac, ibuprofen, meloxicam, naproxen).

Seizure and migraine coverage criteria

Neurologic/seizure disorder criteria (Epidiolex, Topiramate examples):

Epidiolex seizure criteria: Coverage for Lennox‑Gastaut syndrome requires trial of two generic alternatives for seizure treatment; Dravet syndrome requires trial of two of valproic acid, clobazam, or topiramate; coverage for seizures associated with tuberous sclerosis complex requires trial of two generic alternatives.

Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug.

Topiramate migraine prevention: Coverage for migraine prevention requires trial of at least two generic alternatives for migraine prevention, or inability to swallow tablets/capsules.

Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug.

Per-product PA summaries

Each listed product entry summarizes PA criteria status and select specific requirements when present.

General product PA statements: Many products are listed with 'Indications: All Medically-accepted Indications' and note whether prerequisite Part D drugs are required; required medical information, exclusions, and coverage duration are indicated where present.

See individual product entries for specific clinical requirements (examples cited in other blocks).

Products with explicit coverage conditions

Specific coverage conditions present for some products:

Forteo (Teriparatide): Coverage requires documentation of bone mineral density (BMD) T‑score ≤ -2.5; 2‑year coverage requires trial of specified agents or inability to tolerate them.T-score ≤ -2.5

Prerequisite Part D drug may be required per product entry.

Gattex: Coverage requires documentation of dependence on parenteral support for 12 months or greater.Parenteral support ≥ 12 months

Coverage duration: One Year.

Fruzaqla: Coverage for metastatic colorectal cancer requires trial of fluoropyrimidine-, oxaliplatin-, irinotecan-based chemotherapy and an anti‑VEGF therapy.

Prerequisite Part D drug required as noted.

Fotivda: Coverage for advanced renal cell carcinoma requires trial of two or more prior systemic therapies.

Prerequisite Part D drug required.

GLP-1 Agonists (e.g., Mounjaro, Ozempic, Rybelsus, Trulicity)

Coverage conditions for GLP-1 agonists

GLP-1 coverage requirements: Covered when ALL of the following are met: patient requires ongoing treatment for type 2 diabetes mellitus OR medical records confirm diagnosis of T2DM with one of the following laboratory values: A1c ≥ 6.5% OR fasting plasma glucose ≥ 126 mg/dL OR 2‑hour plasma glucose ≥ 200 mg/dL during OGTT; agent is not used solely for weight loss.A1c >= 6.5% OR FPG >= 126 mg/dL OR 2‑hr PG >= 200 mg/dL

Coverage Duration: 1 Year; Exclusion: excluded if used for weight loss only.

Adalimumab products and other biologics

Coverage conditions for adalimumab (Humira and biosimilars) and other biologics

Biologic coverage general: Covered when ALL of the following are met: documented diagnosis matching the indication (e.g., moderately to severely active RA, active polyarticular JIA, active PsA, moderate to severe plaque psoriasis, active AS, moderately to severely active Crohn's disease or ulcerative colitis, moderate to severe HS, qualifying non‑infectious uveitis); trial and failure or intolerance of required prerequisite therapies as specified per indication (e.g., trial of one DMARD for RA; trial of one NSAID for AS); not used in combination with another biologic or targeted DMARD indicated for the same condition; reauthorization requires documentation of positive clinical response.N/A

Coverage Duration commonly 1 Year; Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug for many biologic entries.

Per-product prior authorization criteria (representative)

Covered when product-specific PA criteria are met as enumerated in each product block

Product-level PA requirements: Indication aligns with 'All Medically-accepted Indications' or specific indication language in block; Exclusion Criteria absent unless specified; Required medical information as listed; Coverage duration typically 1 year; Reauthorization requires documentation of positive clinical response.

Per-product variations exist (see individual product block).

Indication-specific prerequisite therapy and diagnosis requirements

Coverage for specific autoimmune/arthritic indications requires trials of specified therapies

Rheumatoid Arthritis (RA): Diagnosis of moderately to severely active RA AND trial of one DMARD (e.g., methotrexate, leflunomide, sulfasalazine).

Coverage duration 1 year.

Polyarticular Juvenile Idiopathic Arthritis (JIA): Diagnosis of active polyarticular JIA AND trial of one of the following DMARDs: leflunomide or methotrexate.

Ankylosing Spondylitis (AS): Diagnosis of active AS AND trial of one NSAID (e.g., diclofenac, ibuprofen, meloxicam, naproxen).

Plaque psoriasis: Diagnosis of moderate to severe chronic plaque psoriasis.

Crohn's Disease/Ulcerative Colitis: Diagnosis of moderately to severely active disease as specified for each condition.

Hidradenitis Suppurativa (HS): Diagnosis of moderate to severe HS.

Uveitis: Diagnosis of non-infectious uveitis classified as intermediate, posterior, or panuveitis.

Product-specific coverage summaries

Coverage and PA notes for listed products (summaries of flags present in the document segment).

General Indications: Many products list 'All Medically-accepted Indications' or 'All FDA-approved Indications' as the indication statement.

See product-specific entries for additional conditions.

Coverage Duration: Several products specify a coverage duration of one year where noted.1 Year

Prerequisite Therapy: Certain products require prior specific therapy trials (examples: Inqovi requires azacitidine; isotretinoin requires trial of an oral antibiotic or benzoyl peroxide topical; Inlyta requires trial of one prior systemic therapy and combination for first-line RCC).

Covered when ALL of the following are met: Agent: Acitretin; Indications: All medically-accepted indications. Coverage Duration: One Year. Prerequisite Therapy: Criteria does not require use of a prerequisite Part D drug. No age, prescriber, required medical information, or exclusion criteria are specified in this excerpt. (See product PA entry for Acitretin.)

Deferasirox (Jadenu) is listed with prior authorization required. Indications: All medically-accepted indications. Coverage Duration: One Year. The product entry indicates that a prerequisite Part D drug is not required for authorization in this excerpt.

Joenja (for activated phosphoinositide 3‑kinase delta syndrome, APDS) requires specific genetic and clinical documentation for prior authorization. Coverage requires: 1) a diagnosis of APDS with an associated PI3Kδ mutation; 2) a documented variant in PIK3CD or PIK3R1; and 3) documented symptoms consistent with APDS (for example, nodal or extranodal lymphoproliferation, recurrent oto‑sino‑pulmonary infections, or organ dysfunction). Coverage Duration: One Year. The Joenja entry also notes an exclusion that it cannot be used in combination with an immunosuppressive medication for APDS in this excerpt.

Kerendia (finerenone) is covered for chronic kidney disease associated with type 2 diabetes mellitus. For the heart failure indication with left ventricular ejection fraction ≥40%, prior authorization requires a trial of an SGLT2 inhibitor (e.g., empagliflozin or dapagliflozin) unless contraindicated or the patient is intolerant. Coverage Duration: One Year. The product entry indicates that a prerequisite Part D drug is required for certain heart failure indications.

Representative product-level prior authorization notes for Kerendia in this excerpt indicate: Indication: chronic kidney disease associated with type 2 diabetes; for some heart failure uses (LVEF ≥40%) a trial of an SGLT2 inhibitor is required unless contraindicated. Coverage Duration: One Year. Providers should submit medical documentation showing the required prior therapy or contraindication/intolerance to SGLT2 inhibitors as applicable.

Kevzara (sarilumab) coverage for rheumatoid arthritis requires a diagnosis of moderately to severely active RA and trials of specified agents as prerequisite therapy. The entry prohibits concurrent use with another biologic or targeted DMARD indicated for the same condition and requires documentation of positive clinical response for reauthorization. Coverage Duration: One Year. Providers must document the required prior trials per the product entry.

Timed 25‑Foot Walk (T25FW) — baseline test required prior to initiation

Timed 25‑Foot Walk (T25FW)Baseline T25FW test required prior to initiation for dalfampridine (MS treatment)

Applicable product(s)Dalfampridine ER

ExclusionExcluded for use if patient is wheelchair‑bound or becomes wheelchair‑bound

Prerequisite therapyCriteria does NOT require use of a prerequisite Part D drug

Eosinophil count — initiation thresholds

Eosinophil thresholdEosinophil count ≥ 150 cells per microliter required for eosinophilic asthma at initiation

Product exampleDupixent (eosinophilic asthma indication)

Additional COPD thresholdSome COPD criteria require eosinophil count ≥ 300 cells/µL

Reauthorization noteReauthorization requires documentation of positive clinical response

Minimum patient weight — 40 kilograms

Minimum patient weightPatient must weigh at least 40 kilograms

Minimum age (where noted)Minimum age requirement may apply (e.g., 12 years for some products)

Product exampleEbglyss — weight and age requirements documented

Minimum age for some products — 12 years

Minimum ageAt least 12 years of age required for some products (example: Ebglyss listed age ≥12 years)

Age varies by productOther products may specify different minimum ages by indication (see product-specific criteria)

Authorization impactPatient age must be documented to meet authorization criteria (age restrictions listed in product entries)

Prior Authorization, Documentation and Actionable Notes

Prior Authorization

Augtyro — prior authorization (1 year)

Prior authorization (PA) is required for Augtyro; coverage duration is one year and the product entry indicates coverage for all medically‑accepted indications with no prerequisite Part D drug required.

Prior Authorization

Auryxia — prior authorization (1 year)

Prior authorization is required for Auryxia with a coverage duration of one year; the entry indicates no prerequisite Part D drug is required.

Step Therapy

Auvelity — trial of bupropion + one other agent required

Auvelity requires prior authorization for major depressive disorder and coverage requires documentation of a trial of bupropion and one other agent (prerequisite Part D drug required).

Prior Authorization

Ayvakit — prior authorization (1 year)

Ayvakit requires prior authorization with coverage duration one year; the product entry indicates no prerequisite Part D drug is required.

Step Therapy

Balversa — prior systemic therapy required

Balversa requires prior authorization for locally advanced or metastatic urothelial carcinoma and coverage requires prior systemic therapy (prerequisite Part D drug required).

Step Therapy

Banzel — trial of divalproex (required)

Banzel (rufinamide) requires prior authorization and coverage requires a trial of divalproex or a similar agent (prerequisite Part D drug required).

Prior Authorization

Benlysta — prior authorization (1 year)

Benlysta requires prior authorization with a coverage duration of one year; the product entry indicates no prerequisite Part D drug is required.

Step Therapy

Besremi — prerequisite therapy required

Besremi requires prior authorization for polycythemia vera and the entry indicates prerequisite therapy is required (prerequisite Part D drug required).

Prior Authorization

Betaseron — prior authorization (1 year)

Betaseron requires prior authorization with a coverage duration of one year; the entry indicates no prerequisite Part D drug is required.

Step Therapy

Bosulif — prior therapy required

Bosulif requires prior authorization for accelerated or blast phase Ph+ CML and coverage requires a trial of prior therapy (prerequisite Part D drug required).

Prior Authorization

Braftovi — combination and prior therapy requirements

Braftovi requires prior authorization for BRAF V600E/V600K indications and coverage often requires combination use with specified agents and, in some settings, prior therapy (prerequisite Part D drug required).

Step Therapy

Briviact — levetiracetam + one other agent required

Briviact requires prior authorization and coverage requires a trial of levetiracetam and one other agent (prerequisite Part D drug required).

Documentation Required

Bronchitol — tolerance test documentation required

Bronchitol requires prior authorization; providers must document that the member has passed a Bronchitol tolerance test. Coverage duration is one year and no prerequisite Part D drug is required.

Document Bronchitol tolerance test passed at authorization

Step Therapy

Brukinsa — specified prior therapies required

Brukinsa requires prior authorization for hematologic malignancies and coverage requires trials of specified prior therapies (e.g., Calquence, anti‑CD20 regimens, Imbruvica); prerequisite Part D drug required.

Denial Risk

Budesonide ER — maintenance of remission in UC excluded

Budesonide ER requires prior authorization; coverage will not be provided for maintenance of remission in ulcerative colitis. No prerequisite Part D drug is required for other indications.

Do not request PA for maintenance of remission in UC — coverage not provided

Step Therapy

Bysanti — antipsychotic trial requirements

Bysanti requires prior authorization with coverage noted as PLAN YEAR; for schizophrenia in adults, providers must document trials of lurasidone and paliperidone; for other indications a trial of at least two listed generic antipsychotics is required (prerequisite Part D drug required).

Prior Authorization

Prior authorization — PA required; typical 1‑year duration

Prior authorization is required for many products; the common default coverage duration is one year and providers must follow product‑specific PA instructions when submitting requests.

Step Therapy / Prerequisite Trials

Step	Requirement
1
Criteria DOES NOT require use of a prerequisite Part D drug

Step	Requirement
1
Trial of bupropion and one other agent required for Major Depressive Disorder (Auvelity).

Step	Requirement
1
For schizophrenia (Bysanti): trial of lurasidone and paliperidone required; for other indications: trial of at least two of the listed generic antipsychotics (aripiprazole, asenapine, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone).

Step	Requirement
1
Trial of one NSAID is required prior to coverage for certain Cosentyx indications (e.g., ankylosing spondylitis, non‑radiographic axial spondyloarthritis, enthesitis‑related arthritis).

Step	Requirement
1
Trials of specified therapies are required before coverage where noted (examples include topical high‑potency corticosteroids or listed systemic immunomodulators for atopic dermatitis; trials of generic alternatives for certain seizure/migraine indications).

Step	Requirement
1
Forteo (teriparatide): 2‑year coverage requires documentation of BMD T‑score ≤ -2.5 and trial of specified therapies (e.g., listed agents or inability to be treated with them).

Step	Requirement
1
Fotivda: coverage for advanced renal cell carcinoma requires trial of two or more prior systemic therapies.

Step	Requirement
1
Fruzaqla: coverage for metastatic colorectal cancer requires trial of fluoropyrimidine‑, oxaliplatin‑, and irinotecan‑based chemotherapy and an anti‑VEGF therapy (additional requirements for RAS wild‑type as noted).

Step	Requirement
1
Fycompa: coverage requires trial of two generic therapies prior to coverage.

Step	Requirement
1
Prerequisite therapy required for certain indications (e.g., RA, polyarticular JIA, ankylosing spondylitis): trials of specified non‑biologic therapies or DMARDs (e.g., methotrexate, leflunomide, sulfasalazine for RA; NSAID trial for AS) are required before biologic coverage.

Step	Requirement
1
Certain products require prior or combination therapies; for example, Inlyta requires trial of one prior systemic therapy and first‑line RCC use must be in combination with avelumab or pembrolizumab.

Step	Requirement
1
Jakafi: trial of one or two lines of systemic therapy is required for certain indications (e.g., polycythemia vera).

Step	Requirement
1
Jaypirca: for mantle cell lymphoma, coverage requires a trial of two lines of systemic therapy including a BTK inhibitor.

Step	Requirement
1
Livtencity (post‑transplant CMV): trial of valganciclovir, cidofovir, or foscarnet is required prior to coverage.

Step	Requirement
1
Lonsurf: trials of fluoropyrimidine‑, oxaliplatin‑, and irinotecan‑based chemotherapy and an anti‑VEGF therapy are required; for RAS wild‑type metastatic colorectal cancer additional anti‑EGFR therapy is required.

Step	Requirement
1
Lynparza: trials of platinum‑based chemotherapy or other specified agents per indication (varies by tumor type) are required prior to coverage.

Step	Requirement
1
Mekinist: when used as monotherapy for BRAF V600E/K mutant melanoma, prior trials as specified are required (e.g., trial of vemurafenib + cobimetinib) and/or combination use with dabrafenib per indication.

Initial Therapy and Entry Requirements

Reauthorization and Continuation Requirements

Documentation Required

Provide reauthorization evidence of clinical response

Providers must supply PA summaries and product‑specific documentation; reauthorization typically requires demonstration of clinical benefit (positive response) for continued coverage.

Documentation Required

Document positive response for biologic reauthorization

Reauthorization for Dupixent and other listed biologics requires documentation that the patient has had a positive clinical response to therapy; submit such clinical notes at reauthorization.

Required Measurements, Age/Weight, and Other Key Values

inv-59: Parenteral support duration / BMD T-score — Parenteral support ≥ 12 months; T-score ≤ -2.5

Parenteral supportDocumentation of dependence on parenteral support for ≥ 12 months is required for coverage (e.g., Gattex).

BMD T‑scoreBone mineral density T‑score ≤ -2.5 is required for teriparatide (Forteo) coverage documentation.

Coverage duration noteProduct entries with these requirements commonly list coverage duration as one year (per product block).

Definitions and Document Labels

inv-164: Prior Authorization — Prior Authorization (PA)

DefinitionPrior Authorization (PA) — clinical and/or administrative criteria must be met before coverage is provided.

ActionProviders must request PA via the pharmacy help desk per document instructions.

ConsequenceFailure to obtain required PA may result in claim denial.

inv-165: Step Therapy — Step Therapy (ST)

DefinitionStep Therapy (ST) — drugs subject to ST may require prior treatment with one or more formulary drugs before coverage.

Formulary noteDrugs subject to ST are identified on the formulary; see formulary for specific ST requirements.

Acitretin exampleAcitretin entry indicates prerequisite therapy is NOT required (example of ST labeling usage).

inv-166: PA Criteria — Indicates the presence of prior authorization criteria details for the listed product.

MeaningPA Criteria — indicates that detailed prior authorization criteria exist for the listed product (referenced as 'Criteria Details').

UsageOften accompanied by product fields: Indications, Exclusion Criteria, Required Medical Information, Age/Prescriber Restrictions, Coverage Duration, Other Criteria.

Provider implicationProviders must follow product‑specific PA criteria when requesting authorization.

inv-167: Prerequisite Therapy — Indicates whether the criteria require use of a prerequisite Part D drug.

DefinitionPrerequisite Therapy — denotes whether criteria require use of a prerequisite Part D drug before authorization.

ExampleKerendia: certain heart failure indications require trial of an SGLT2 inhibitor unless contraindicated (documented as prerequisite therapy).

Varies by productSome products require prerequisite Part D drug trials; others explicitly do not.

inv-168: Required Medical Information — Product-specific clinical information required for authorization such as minimum weight.

DefinitionRequired Medical Information — product‑specific clinical information required for authorization (e.g., minimum weight, age).

ExampleEbglyss: 'Patient must weigh at least 40 kilograms' is listed under Required Medical Information.

PurposeSubmitted medical records must support required medical information at authorization and reauthorization.

inv-170: GLP-1 agonists — Included agents listed (e.g., Mounjaro, Ozempic, Rybelsus, Trulicity) with PA criteria; excluded if used solely for weight loss.

Included agentsGLP-1 agonists listed include Mounjaro, Ozempic, Rybelsus, Trulicity.

Coverage conditionCoverage requires documentation of T2DM diagnosis or qualifying lab values; excluded if used solely for weight loss.

Required evidenceAcceptable lab evidence includes A1c ≥ 6.5% OR fasting plasma glucose ≥ 126 mg/dL OR 2‑hour OGTT ≥ 200 mg/dL.

inv-171: Biologic DMARD coverage conditions — Coverage for biologics (e.g., adalimumab products) requires diagnosis-specific criteria, trials of conventional DMARDs or NSAIDs for cert...

Coverage conditionsBiologic DMARD coverage requires diagnosis‑specific criteria and trials of conventional DMARDs or NSAIDs for certain indications.

Combination exclusionBiologics cannot be used in combination with another biologic or targeted DMARD indicated for the same condition.

ReauthorizationReauthorization requires documentation of a positive clinical response to therapy.

inv-175: Activated phosphoinositide 3-kinase delta syndrome (APDS) — A primary immunodeficiency associated with PI3Kδ mutations; Joenja coverage for APDS requires documented PI3Kδ mutation (PIK3CD or PIK3R1...

Condition describedActivated phosphoinositide 3‑kinase delta syndrome (APDS) — a primary immunodeficiency associated with PI3Kδ mutations.

Joenja requirementJoenja coverage for APDS requires documented PI3Kδ mutation (variant in PIK3CD or PIK3R1) and documented APDS‑related clinical features.

ExclusionFor APDS, Joenja cannot be used in combination with an immunosuppressive medication.

inv-176: Coverage Duration — The default coverage duration noted for several products is 1 YEAR.

Default durationCoverage duration commonly listed as 1 YEAR for many products.

Product varianceSome products list PLAN YEAR or other durations; check individual product block for specifics.

Provider implicationPA approvals are typically issued for the stated coverage duration and require reauthorization thereafter.

Program Background

This formulary prior authorization and step therapy program monitors the use of certain medications to help ensure appropriate, safe, and cost‑effective drug therapy. Clinical criteria reflect current medical evidence and recommendations of the Blues' Pharmacy & Therapeutics Committee; providers must request prior authorization via the pharmacy help desk and meet the product‑specific PA and step therapy requirements before coverage is provided.

Policy Revision History

2026-07-01policy_effectiveLatest

Policy effective date set to 2026-07-01; document last revised 2026-07-01.

Policy Summary

Payerblue cross blue shield - michigan

PolicyAcitretin prior authorization and coverage summary

Policy CodePolicy Y0074_Grp26JulHVEnhPAST_C

Change TypeNo material change

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateJul 1, 2026

Key ActionRequest prior authorization via the pharmacy help desk and provide required clinical documentation to support coverage.

SourceLink

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Acitretin prior authorization and coverage summary

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Policy Summary

Payerblue cross blue shield - michigan

PolicyAcitretin prior authorization and coverage summary

Policy CodePolicy Y0074_Grp26JulHVEnhPAST_C

Change TypeNo material change

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateJul 1, 2026

Key ActionRequest prior authorization via the pharmacy help desk and provide required clinical documentation to support coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredPA required

Not requiredPrerequisite therapy

1 YearCoverage duration

Medicare+ & PDPPlans covered

20+Products listed

Coverage Criteria and Product Summaries

Initial Therapy / General Coverage Parameters

Covered when ALL of the following are met

No age, prescriber, exclusion, or required medical information specified in this excerpt.

Product PA summary

Products listed with brief PA attributes (examples shown); detailed medical necessity criteria are not included in this section.

Detailed stepwise clinical criteria not provided in this section.

General product PA coverage

Covered when product-specific PA criteria are met; many entries state 'All medically-accepted indications' with PA documentation and duration requirements.

General PA coverage: Product is covered for all medically-accepted indications when PA criteria and required documentation are provided; many products have a 1 year coverage duration.

See individual product notes for exclusions and prerequisite therapy requirements.

Cosentyx (secukinumab) coverage

Cosentyx specific coverage conditions

Cosentyx cannot be used in combination with another biologic or targeted DMARD for the same condition; reauthorization requires documentation of positive clinical response.

Copiktra coverage

Copiktra coverage for relapsed/refractory CLL

Copiktra prerequisites: Coverage for relapsed or refractory chronic lymphocytic leukemia (CLL) requires documentation of prior therapies; policy indicates requirement of at least two prior therapies.

Prerequisite therapy required as stated in product entry.

Cystaran - Indications and Duration

Cystaran

Cystaran coverage: Covered for all medically-accepted indications; Coverage Duration: One Year; Prerequisite Therapy: Criteria DOES NOT require use of a prerequisite Part D drug.

No additional required medical information specified in this excerpt.

Dalfampridine - Indications and Exclusion

Dalfampridine ER

No prerequisite Part D drug required.

Doptelet - Indications

Doptelet

Coverage duration and other specifics per product entry.

Dupixent - Indications and Reauthorization

Dupixent

Coverage Duration: 1 Year; Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug.

Ebglyss - Indications and Limits

Ebglyss

Reauthorization requires documentation of positive clinical response.

Product-specific PA summary (examples)

Product-specific PA criteria examples from this section (partial list):

Reauthorization requires documentation of positive clinical response.

Enbrel indication-specific criteria

Rheumatologic indications (Enbrel example):

RA initial requirement: Coverage for rheumatoid arthritis requires diagnosis of moderately to severely active RA and trial of one DMARD (e.g., methotrexate, leflunomide, sulfasalazine).

Reauthorization requires documentation of positive clinical response.

Ankylosing spondylitis requirement: Coverage for ankylosing spondylitis requires diagnosis of active AS and trial of one NSAID (e.g., diclofenac, ibuprofen, meloxicam, naproxen).

Seizure and migraine coverage criteria

Neurologic/seizure disorder criteria (Epidiolex, Topiramate examples):

Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug.

Topiramate migraine prevention: Coverage for migraine prevention requires trial of at least two generic alternatives for migraine prevention, or inability to swallow tablets/capsules.

Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug.

Per-product PA summaries

Each listed product entry summarizes PA criteria status and select specific requirements when present.

See individual product entries for specific clinical requirements (examples cited in other blocks).

Products with explicit coverage conditions

Specific coverage conditions present for some products:

Prerequisite Part D drug may be required per product entry.

Gattex: Coverage requires documentation of dependence on parenteral support for 12 months or greater.Parenteral support ≥ 12 months

Coverage duration: One Year.

Fruzaqla: Coverage for metastatic colorectal cancer requires trial of fluoropyrimidine-, oxaliplatin-, irinotecan-based chemotherapy and an anti‑VEGF therapy.

Prerequisite Part D drug required as noted.

Fotivda: Coverage for advanced renal cell carcinoma requires trial of two or more prior systemic therapies.

Prerequisite Part D drug required.

GLP-1 Agonists (e.g., Mounjaro, Ozempic, Rybelsus, Trulicity)

Coverage conditions for GLP-1 agonists

Coverage Duration: 1 Year; Exclusion: excluded if used for weight loss only.

Adalimumab products and other biologics

Coverage conditions for adalimumab (Humira and biosimilars) and other biologics

Coverage Duration commonly 1 Year; Prerequisite Therapy: Criteria DOES require use of a prerequisite Part D drug for many biologic entries.

Per-product prior authorization criteria (representative)

Covered when product-specific PA criteria are met as enumerated in each product block

Per-product variations exist (see individual product block).

Indication-specific prerequisite therapy and diagnosis requirements

Coverage for specific autoimmune/arthritic indications requires trials of specified therapies

Rheumatoid Arthritis (RA): Diagnosis of moderately to severely active RA AND trial of one DMARD (e.g., methotrexate, leflunomide, sulfasalazine).

Coverage duration 1 year.

Polyarticular Juvenile Idiopathic Arthritis (JIA): Diagnosis of active polyarticular JIA AND trial of one of the following DMARDs: leflunomide or methotrexate.

Ankylosing Spondylitis (AS): Diagnosis of active AS AND trial of one NSAID (e.g., diclofenac, ibuprofen, meloxicam, naproxen).

Plaque psoriasis: Diagnosis of moderate to severe chronic plaque psoriasis.

Crohn's Disease/Ulcerative Colitis: Diagnosis of moderately to severely active disease as specified for each condition.

Hidradenitis Suppurativa (HS): Diagnosis of moderate to severe HS.

Uveitis: Diagnosis of non-infectious uveitis classified as intermediate, posterior, or panuveitis.

Product-specific coverage summaries

Coverage and PA notes for listed products (summaries of flags present in the document segment).

General Indications: Many products list 'All Medically-accepted Indications' or 'All FDA-approved Indications' as the indication statement.

See product-specific entries for additional conditions.

Coverage Duration: Several products specify a coverage duration of one year where noted.1 Year

Timed 25‑Foot Walk (T25FW) — baseline test required prior to initiation

Timed 25‑Foot Walk (T25FW)Baseline T25FW test required prior to initiation for dalfampridine (MS treatment)

Applicable product(s)Dalfampridine ER

ExclusionExcluded for use if patient is wheelchair‑bound or becomes wheelchair‑bound

Prerequisite therapyCriteria does NOT require use of a prerequisite Part D drug

Eosinophil count — initiation thresholds

Eosinophil thresholdEosinophil count ≥ 150 cells per microliter required for eosinophilic asthma at initiation

Product exampleDupixent (eosinophilic asthma indication)

Additional COPD thresholdSome COPD criteria require eosinophil count ≥ 300 cells/µL

Reauthorization noteReauthorization requires documentation of positive clinical response

Minimum patient weight — 40 kilograms

Minimum patient weightPatient must weigh at least 40 kilograms

Minimum age (where noted)Minimum age requirement may apply (e.g., 12 years for some products)

Product exampleEbglyss — weight and age requirements documented

Minimum age for some products — 12 years

Minimum ageAt least 12 years of age required for some products (example: Ebglyss listed age ≥12 years)

Age varies by productOther products may specify different minimum ages by indication (see product-specific criteria)

Authorization impactPatient age must be documented to meet authorization criteria (age restrictions listed in product entries)

Prior Authorization, Documentation and Actionable Notes

Prior Authorization

Augtyro — prior authorization (1 year)

Prior Authorization

Auryxia — prior authorization (1 year)

Prior authorization is required for Auryxia with a coverage duration of one year; the entry indicates no prerequisite Part D drug is required.

Step Therapy

Auvelity — trial of bupropion + one other agent required

Auvelity requires prior authorization for major depressive disorder and coverage requires documentation of a trial of bupropion and one other agent (prerequisite Part D drug required).

Prior Authorization

Ayvakit — prior authorization (1 year)

Ayvakit requires prior authorization with coverage duration one year; the product entry indicates no prerequisite Part D drug is required.

Step Therapy

Balversa — prior systemic therapy required

Balversa requires prior authorization for locally advanced or metastatic urothelial carcinoma and coverage requires prior systemic therapy (prerequisite Part D drug required).

Step Therapy

Banzel — trial of divalproex (required)

Banzel (rufinamide) requires prior authorization and coverage requires a trial of divalproex or a similar agent (prerequisite Part D drug required).

Prior Authorization

Benlysta — prior authorization (1 year)

Benlysta requires prior authorization with a coverage duration of one year; the product entry indicates no prerequisite Part D drug is required.

Step Therapy

Besremi — prerequisite therapy required

Besremi requires prior authorization for polycythemia vera and the entry indicates prerequisite therapy is required (prerequisite Part D drug required).

Prior Authorization

Betaseron — prior authorization (1 year)

Betaseron requires prior authorization with a coverage duration of one year; the entry indicates no prerequisite Part D drug is required.

Step Therapy

Bosulif — prior therapy required

Bosulif requires prior authorization for accelerated or blast phase Ph+ CML and coverage requires a trial of prior therapy (prerequisite Part D drug required).

Prior Authorization

Braftovi — combination and prior therapy requirements

Step Therapy

Briviact — levetiracetam + one other agent required

Briviact requires prior authorization and coverage requires a trial of levetiracetam and one other agent (prerequisite Part D drug required).

Documentation Required

Bronchitol — tolerance test documentation required

Bronchitol requires prior authorization; providers must document that the member has passed a Bronchitol tolerance test. Coverage duration is one year and no prerequisite Part D drug is required.

Document Bronchitol tolerance test passed at authorization

Step Therapy

Brukinsa — specified prior therapies required

Denial Risk

Budesonide ER — maintenance of remission in UC excluded

Budesonide ER requires prior authorization; coverage will not be provided for maintenance of remission in ulcerative colitis. No prerequisite Part D drug is required for other indications.

Do not request PA for maintenance of remission in UC — coverage not provided

Step Therapy

Bysanti — antipsychotic trial requirements

Prior Authorization

Prior authorization — PA required; typical 1‑year duration

Prior authorization is required for many products; the common default coverage duration is one year and providers must follow product‑specific PA instructions when submitting requests.

Step Therapy / Prerequisite Trials

Step	Requirement
1
Criteria DOES NOT require use of a prerequisite Part D drug

Step	Requirement
1
Trial of bupropion and one other agent required for Major Depressive Disorder (Auvelity).

Step	Requirement
1
For schizophrenia (Bysanti): trial of lurasidone and paliperidone required; for other indications: trial of at least two of the listed generic antipsychotics (aripiprazole, asenapine, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone).

Step	Requirement
1
Trial of one NSAID is required prior to coverage for certain Cosentyx indications (e.g., ankylosing spondylitis, non‑radiographic axial spondyloarthritis, enthesitis‑related arthritis).

Step	Requirement
1
Trials of specified therapies are required before coverage where noted (examples include topical high‑potency corticosteroids or listed systemic immunomodulators for atopic dermatitis; trials of generic alternatives for certain seizure/migraine indications).

Step	Requirement
1
Forteo (teriparatide): 2‑year coverage requires documentation of BMD T‑score ≤ -2.5 and trial of specified therapies (e.g., listed agents or inability to be treated with them).

Step	Requirement
1
Fotivda: coverage for advanced renal cell carcinoma requires trial of two or more prior systemic therapies.

Step	Requirement
1
Fruzaqla: coverage for metastatic colorectal cancer requires trial of fluoropyrimidine‑, oxaliplatin‑, and irinotecan‑based chemotherapy and an anti‑VEGF therapy (additional requirements for RAS wild‑type as noted).

Step	Requirement
1
Fycompa: coverage requires trial of two generic therapies prior to coverage.

Step	Requirement
1
Prerequisite therapy required for certain indications (e.g., RA, polyarticular JIA, ankylosing spondylitis): trials of specified non‑biologic therapies or DMARDs (e.g., methotrexate, leflunomide, sulfasalazine for RA; NSAID trial for AS) are required before biologic coverage.

Step	Requirement
1
Certain products require prior or combination therapies; for example, Inlyta requires trial of one prior systemic therapy and first‑line RCC use must be in combination with avelumab or pembrolizumab.

Step	Requirement
1
Jakafi: trial of one or two lines of systemic therapy is required for certain indications (e.g., polycythemia vera).

Step	Requirement
1
Jaypirca: for mantle cell lymphoma, coverage requires a trial of two lines of systemic therapy including a BTK inhibitor.

Step	Requirement
1
Livtencity (post‑transplant CMV): trial of valganciclovir, cidofovir, or foscarnet is required prior to coverage.

Step	Requirement
1
Lonsurf: trials of fluoropyrimidine‑, oxaliplatin‑, and irinotecan‑based chemotherapy and an anti‑VEGF therapy are required; for RAS wild‑type metastatic colorectal cancer additional anti‑EGFR therapy is required.

Step	Requirement
1
Lynparza: trials of platinum‑based chemotherapy or other specified agents per indication (varies by tumor type) are required prior to coverage.

Step	Requirement
1
Mekinist: when used as monotherapy for BRAF V600E/K mutant melanoma, prior trials as specified are required (e.g., trial of vemurafenib + cobimetinib) and/or combination use with dabrafenib per indication.