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Prior Authorization and Step Therapy Coverage Criteria — Pharmacy & Specialty Drugs

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Rules and criteria for when Blue Cross Blue Shield of Michigan and Blue Care Network require prior authorization or step therapy for medications under their prescription and medical drug benefits; affects prescribing providers and members covered by BCBSM/BCN plans.

Policy Summary

Payerblue cross blue shield - michigan

PolicyPrior Authorization and Step Therapy Coverage Criteria — Pharmacy & Specialty Drugs

Policy CodePolicy N/A

Change TypeNew coverage criteria added

Effective DateN/A

Last ReviewMar 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization and document required prior trials, labs, or genetic testing before submitting requests to avoid denial or member liability.

SourceLink

POLICY UPDATE CHANGES

New coverage criteria published for multiple drugs (e.g., topiramate solution (Eprontia), Camzyos, Furoscix, Fabhalta, Lupkynis) with publish date 3/1/2026 and effective date 5/1/2026.

multiplenew coverage criteria entries in this partial document

3/1/2026publish date for new criteria

5/1/2026effective date for new criteria

1 yeartypical initial approval period

yesNot Covered (NC) flags present

Drug-specific Coverage Criteria (A–Z)

The criteria for medications that need prior authorization or step therapy are based on current medical information and the recommendations of Blue Cross and BCN's Pharmacy and Therapeutics Committee.

Coverage of drugs depends on your prescription drug plan. Not all drugs included in these prior authorization and step therapy guidelines are necessarily covered by your plan.

Denial Risk

NC = Not Covered — Provider action

NC = Not Covered. You may be responsible for the full cost of the medication. Failure to obtain required prior authorization, or failure to meet step therapy requirements, may result in denial of coverage and full member liability for the medication cost.

Coverage denial risk when PA/step therapy not obtained
Not covered products may still be reviewed for medical necessity under the medical benefit

Arcalyst — Coverage Criteria

Arcalyst — Multiple indication branches (CAPS, DIRA, Recurrent Pericarditis) and initial therapy rules

Policy Summary

Payerblue cross blue shield - michigan

PolicyPrior Authorization and Step Therapy Coverage Criteria — Pharmacy & Specialty Drugs

Policy CodePolicy N/A

Change TypeNew coverage criteria added

Effective DateN/A

Last ReviewMar 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization and document required prior trials, labs, or genetic testing before submitting requests to avoid denial or member liability.

SourceLink

On This Page

Initial Therapy - Arcalyst

ONE of the following indications
- CAPS (FCAS, MWS)
  - Diagnosis of Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS)
  - Age ≥ 12 years
  - Laboratory evidence of a genetic mutation OR elevated inflammatory markers plus at least two of six typical CAPS manifestations (urticaria-like rash, cold-triggered episodes, hearing loss, musculoskeletal symptoms, chronic aseptic meningitis, or skeletal abnormalities)
- DIRA
  - Diagnosis of deficiency of interleukin-1 receptor antagonist (DIRA)
  - Laboratory evidence of homozygous genetic mutations of IL1RN
  - Weight ≥ 10 kg
  - Trial and failure, contraindication, or intolerance to Kineret (anakinra)
- Recurrent Pericarditis (RP)
  - Diagnosis of recurrent pericarditis
  - Age ≥ 12 years
  - Trial and treatment failure or intolerance to NSAIDs in combination with colchicine
  - Trial and treatment failure or intolerance to Kineret (anakinra)
ALL of the following
- Arcalyst will not be used in combination with other biologics or targeted DMARDs for the same indication
- Initial approval: 1 year; renewal requires documentation of clinical benefit

Egrifta WR — Coverage Criteria

Egrifta WR initial therapy

ALL of the following

Diagnosis of HIV
Currently receiving antiretroviral therapy (ART)
Medical complication caused by excess abdominal fat
Medical complication due to excess abdominal fat is not responsive to conventional therapy
Initial approval: 6 months; renewal requires clinical benefit documentation

Eltrombopag (Promacta) — Coverage Criteria

Eltrombopag coverage criteria

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Flector — Coverage Criteria

Flector (diclofenac epolamine 1.3% patch) coverage criteria

ALL of the following

Diagnosis of acute pain due to minor strains, sprains, or contusions
Trial of or intolerance to generic oral diclofenac and at least two other oral traditional NSAIDs
Initial approval: 3 months; renewal requires clinical benefit
Coverage will not be provided with concurrent oral NSAID therapy

paragraphs[],

Furoscix — Coverage Criteria

Furoscix coverage criteria

ALL of the following

For treatment of edema in chronic heart failure or chronic kidney disease, including nephrotic syndrome
Patient weight ≥ 43 kg
Patient experiencing increased signs/symptoms of congestion due to fluid overload
Established on background therapy with a loop diuretic
Patient stable for outpatient management and does not require emergency care or hospitalization for heart failure or acute pulmonary edema
For adults: trial and failure, contraindication, or intolerance to Lasix ONYU may be required (per updated criteria)

paragraphs[],

Ravicti — Coverage Criteria

Ravicti coverage criteria

ALL of the following

Diagnosis of urea cycle disorder
Used as adjunctive therapy to dietary management (dietary protein restriction and/or amino acid supplementation)
Trial and treatment failure of Buphenyl (sodium phenylbutyrate)
Initial approval: 1 year; renewal requires demonstration of clinical benefit

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Hemlibra — Coverage Criteria

Hemlibra coverage criteria — inhibitor and non-inhibitor branches

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Long-acting opioids — Coverage Criteria and Exclusions

Long-acting opioids — Coverage Criteria

ALL of the following

Diagnosis of moderate to severe chronic pain requiring around-the-clock opioid analgesia for an extended period
Trial and failure or intolerance to three generic long-acting opioids (examples include buprenorphine transdermal patch, tramadol, morphine, fentanyl, methadone)
Initial approval: 1 year; renewal requires evidence of clinical benefit
Coverage will not be provided if the patient is on more than one long-acting opioid concurrently

paragraphs[],

Gattex — Coverage Criteria

Gattex (teduglutide) coverage criteria

ALL of the following

Diagnosis of Short Bowel Syndrome (SBS)
Dependent on parenteral support ≥ 12 months
Initial approval: 1 year
Renewal requires reduction in ≥20% of weekly parenteral nutrition volume or IV fluid volume to document clinical benefit

paragraphs[],

Icatibant (Firazyr) — Coverage Criteria

Icatibant for acute hereditary angioedema (HAE) attacks

ALL of the following

Treatment of acute attacks of hereditary angioedema (HAE)
Diagnosis confirmed with laboratory findings: low C4 and low C1 inhibitor (antigenic or functional)
Prescribed by an immunologist, allergist, or hematologist
Not to be used in combination with other products indicated for acute HAE attacks
Initial approval: 1 year; renewal requires objective data documenting ≥50% improvement in time to relief and maintenance of improvement

paragraphs[],

Imcivree — Coverage Criteria

Imcivree coverage criteria

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Immunoglobulins (IV/SC) — Coverage Criteria

Immunoglobulin coverage criteria — preferred vs non-preferred and step therapy

ALL of the following

Coverage for IV/SC immunoglobulin products follows step therapy: trial and failure of preferred products is required prior to coverage of non-preferred products
Examples: Preferred agents listed in the policy (e.g., specified brand preferred list); coverage of non-preferred requires documentation of trial and failure to all preferred options
Documentation requirements: indication-specific labs, prior therapy details, and provider attestations per product

paragraphs[],

Kalydeco — Coverage Criteria

Kalydeco coverage criteria for Cystic Fibrosis

ALL of the following

Diagnosis of Cystic Fibrosis (CF)
FDA-approved gene mutation confirmed by genetic testing
Initial approval: 1 year; renewal requires documentation of clinical benefit

paragraphs[],

Initial Authorization and Start-of-Treatment Requirements

Prior Authorization

General prior authorization duration — typical 1 year

Most prior authorizations are initially approved for one year; providers must request renewal and demonstrate continued clinical benefit and that criteria remain met.

Standard initial approval period: commonly 1 year (document notes this as the usual duration).
Renewal requires documentation the medication is providing clinical benefit and that original criteria continue to be met.

Step Therapy

ADHD liquid/ODT step therapy — trial of generics required

For Adzenys ER/Adzenys XR‑ODT (ADHD liquids/ODT), step therapy requires documented trial and treatment failure or intolerance to both a generic methylphenidate and a generic amphetamine product (one must be long‑acting) unless the member cannot swallow tablets/capsules.

If member cannot swallow tablets/capsules, a failed trial of an agent that can be opened and sprinkled may substitute.

Prior Authorization

Oncology/OncoHealth prior authorization — shorter approval windows

Oncology prior authorization requests for pharmacy‑benefit oncology/supportive care drugs must be submitted through the OncoHealth Oncology Value Management program (via Availity); OncoHealth approvals are issued for at least 60 days and up to six months.

Coverage requires use consistent with FDA labeling or accepted consensus guidelines for off‑label use (e.g., NCCN).
Approvals through OncoHealth: minimum 60 days, up to six months.

Renewal / Continuation Requirements

Documentation Required

Monitoring & documentation required at renewal

Renewal requests must include recent monitoring data where specified (examples: platelet counts for thrombopoietic agents, IGF‑1 for growth hormone therapies, bleed counts/inhibitor titers for hemophilia agents) to demonstrate ongoing benefit.

Doptelet/eltrombopag renewal requires recent platelet counts within specified targets or dose‑adjustment documentation.
Growth hormone renewals require IGF‑1 and stimulation test documentation per criteria.
Hemlibra/hemophilia renewals require documentation of bleed frequency and inhibitor titer (>5 BU/mL) when applicable.

Step Therapy Rules and Required Prior Trials

Drug	Required prior trials / Step therapy
Adzenys ER (amphetamine suspension)	Treatment failure or intolerance to both a generic methylphenidate and a generic amphetamine product, one of which must be a long‑acting formulation; OR inability to swallow with failed trial of an agent that can be opened and sprinkled (methylphenidate ER, Adderall XR).
Akynzeo (CINV)	Trial of a generic 5‑HT3 antagonist (e.g., generic ondansetron or granisetron), a preferred NK1 antagonist (e.g., aprepitant/Emend), and a glucocorticoid (dexamethasone).
Almotriptan (Axert)	Trial of two generic triptans (examples: sumatriptan, rizatriptan, naratriptan, or zolmitriptan) prior to approval.
Auvelity (depression)	Treatment failure of at least three antidepressant agents before coverage.
Arikayce (inhaled amikacin)	Indication-specific requirements; prior therapies and PA apply (document lists initial approval 1 year).
[{"text":"Austedo XR (deutetrabenazine)",\
status":""},{"text":"For Huntington's chorea: trial and failure/contraindication/intolerance to generic tetrabenazine; for tardive dyskinesia, indication‑specific criteria. Initial approval typically 1 year.","status":""}]
Brivaracetam (Briviact)	Treatment failure or intolerance to three generic preferred antiepileptic alternatives prior to approval.
Belbuca (buprenorphine buccal film)	Trial and failure or intolerance to two long‑acting opioids (one must be buprenorphine transdermal patch); not covered if on more than one long‑acting opioid concurrently.
Caplyta (lumateperone)	Trial and failure, contraindication, or intolerance to two preferred second‑generation antipsychotics prior to coverage.
Dayvigo (lemborexant)	Prior trial and treatment failure or intolerance to three immediate‑release hypnotics (e.g., zolpidem, eszopiclone, zaleplon, trazodone, doxepin) and trial/failure of Belsomra required. Combination with other sedative hypnotics not allowed.
Deferiprone (Ferriprox)	Tablets: age ≥8 and trial/failure/intolerance to prior chelation (Jadenu/Exjade) per thalassemia chelation criteria; solution: age ≥3 with analogous prior‑therapy requirements.
Descovy (PrEP)	Member must meet high‑risk PrEP criteria and not be taking concomitant antiretroviral therapy; renewal requires recent negative HIV test. (Selection criteria rather than classic step trials.)
Diacomit (stiripentol)	Dravet syndrome: trial and failure, contraindication, or intolerance to two generics (valproic acid, clobazam, or topiramate) and used in combination with clobazam.
Daybue (Rett syndrome)	Diagnosis‑specific criteria with age ≥2; PA/step expectations and documentation required prior to approval.
Flector patch (diclofenac epolamine)	Trial of or intolerance to generic oral diclofenac and at least two other oral traditional NSAIDs prior to coverage; not covered with concurrent oral NSAIDs. Initial approval commonly 3 months.
Frovatriptan (Frova)	Trial of two generic triptans (e.g., sumatriptan, rizatriptan, naratriptan, zolmitriptan) required before approval.
Entyvio Pen (vedolizumab)	Trial and treatment failure of an adequate course of conventional therapy AND trial/failure of TWO listed biologic/targeted agents (examples: preferred adalimumab biosimilar, Simponi, Skyrizi, preferred ustekinumab biosimilar, Tremfya, Xeljanz/XR, or Rinvoq) prior to approval.
Emgality (galcanezumab) 120 mg	Preventive migraine: trial of two medications from two different classes for migraine prevention required prior to coverage; not to be used with other CGRP antagonists for prevention.
Gemtesa (OAB)	Trial and failure or intolerance to two preferred overactive bladder therapies prior to coverage.
Growth hormone (non‑preferred products)	Coverage for non‑preferred GH products requires failure of ALL preferred agents (Genotropin and Norditropin) before approval.
Mavyret (hepatitis C)	Preferred Epclusa should be tried; if treatment‑experienced or cirrhosis present, documentation of prior regimens is required (step/per‑case review).
Neupro (rotigotine)	Parkinson's disease: treatment failure or intolerance to generic pramipexole (Mirapex); RLS: failure/intolerance to generic pramipexole, ropinirole, and gabapentin prior to coverage.
Oxtellar XR (oxcarbazepine ER)	Treatment failure or intolerance to at least three generic alternatives (one must be generic oxcarbazepine) prior to approval.
Orencia SC (abatacept)	RA: trial and failure of one DMARD (≥3 months) AND trial and failure of two specified biologic/targeted agents (eg Enbrel, preferred adalimumab biosimilar, Simponi, Rinvoq/LQ*, Xeljanz/XR) depending on indication/age before coverage.
Qsymia (phentermine/topiramate ER)	Attestation of BMI criteria and physician attestation of participation in lifestyle modifications; not to be used with other weight‑loss products (selection criteria rather than specific drug step trials).
Rinvoq (upadacitinib)	Requires trial and failure of one DMARD (≥3 months) and trial and failure of one or more TNF inhibitors (or specified sequencing) prior to approval for RA and other indications.
Topiramate formulations (Eprontia solution, Qudexy XR)	Seizure or Lennox‑Gastaut: treatment failure or intolerance to at least three generic alternatives, one of which must be generic topiramate; Migraine prevention (age ≥12): failure of three generic preventive alternatives (one must be generic topiramate) or inability to swallow tablets/capsules. Initial approval commonly 1 year.
Tlando (oral testosterone)	Trial and failure/contraindication/intolerance to one generic/preferred testosterone product and to Kyzatrex prior to coverage. Initial approval: 1 year.
Topicals and dermatologic agents (Vtama, Opzelura, etc.)	Typically require trial and failure of specified generic topical alternatives (eg topical corticosteroid, topical calcineurin inhibitor, topical fluorouracil/imiquimod for actinic keratosis) before coverage.

Step Therapy

Step therapy — try preferred agents first and document trials

Step therapy requires trying payer‑preferred drugs first; providers must document trials, failures, contraindications, or intolerances to the required prior agents before approval of non‑preferred products.

If required prior therapies are not documented, requests may be denied.
Step therapy applies across many therapeutic classes and individual drug entries—verify the specific prior agents listed for the requested product.

Step Therapy

Step therapy requirements — provide documented prior trials

Many drug entries list step/failure requirements; providers must supply documentation of specific prior trials and reasons for failure or intolerance (examples include trials of Epclusa before Mavyret, two agents before Entyvio Pen, or three generics prior to brivaracetam).

Examples in the formulary list the exact agents/classes that must be tried—use the drug‑specific entry to confirm required comparators.
Document the duration and outcome of each prior trial to support medical necessity.

What Prescribers and Pharmacies Must Do

Prior Authorization

Prior authorization required — submit PA with supporting documentation

Prior authorization is required for many listed medications; providers should submit PA requests with required clinical documentation and note the typical initial approval length (commonly 1 year) and renewal expectations.

Confirm whether the drug is covered under the prescription or medical benefit and follow the appropriate UM drug list if medical‑benefit applies.
Include diagnostic confirmation, prior therapy history, and prescriber specialty when required.

Billing Rule

PA/step therapy applies — check site‑of‑care and OncoHealth pathways

Prior authorization/step therapy rules apply across many products and certain drugs may require site‑of‑care instructions (e.g., OncoHealth submission for oncology pharmacy‑benefit drugs or referral to Utilization Management Medical Drug List for medical‑benefit drugs).

Oncology/supportive care drugs — submit via OncoHealth (Availity).
Some therapies may require medical‑benefit referral or site‑of‑care routing—check the UM Medical Drug List.

Prior Authorization

Drug‑specific PA highlights — follow per‑drug requirements

Providers must follow drug‑specific PA highlights: examples include Arcalyst (diagnosis‑specific genetic/lab evidence and prohibits combination biologic use), Arikayce (MAC diagnosis, age ≥18), Arcalyst/Arikayce/Austedo/Belbuca entries each list the exact prior trials or contraindications required in the drug entry.

Belbuca: requires trial/failure of two long‑acting opioids (one must be buprenorphine patch) and excludes concurrent long‑acting opioid therapy.
Arcalyst: indication‑specific genetic/lab evidence and cannot be used with other biologics/targeted DMARDs.

Documentation Required

Documentation & monitoring required at PA submission

At PA submission include all required diagnostic and monitoring data specified in the drug entry — examples: HIV test for Descovy PrEP renewal, platelet monitoring for thrombopoietic agents, and hemophilia dispensing/bleed history when requesting hemophilia products.

Descovy PrEP renewal requires a negative HIV test within the past 3 months.
Hemophilia products must be prescribed/dispensed by an accredited hemophilia treatment center and include bleed counts/inhibitor titers.

Denial Risk

Denial risk if PA/step therapy not obtained — NC implications

If required prior authorization or step therapy is not obtained or documented, the claim may be denied and the drug could be Not Covered (NC), leaving the member financially responsible.

Verify PA/step therapy requirements and NC matrix status before dispensing to avoid member liability.
Document all prior trials and clinical rationale in the medical record and PA request.

Billing Rule

Medical‑benefit drugs — consult UM Medical Drug List and site‑of‑care guidance

For drugs administered under the medical benefit, refer to the Blue Cross/BCN Utilization Management Medical Drug List for authorization, site‑of‑care, and billing pathway guidance.

Medical‑benefit drugs may have different PA routes and site‑of‑care rules than pharmacy‑benefit drugs.

Billing Rule

Specialty site‑of‑care requirements — dispensing/center rules

Some specialty products require dispensing at specific sites or by specialized centers — examples include Tyvaso/Tyvaso DPI site‑of‑care considerations and hemophilia therapies requiring dispensing via an accredited hemophilia treatment center.

Hemophilia agents: prescribed and dispensed by a hemophilia treatment center per coverage criteria.
Tyvaso: PA requires prior trials of specified PAH agents and may have site‑of‑care restrictions.

Key Numeric / Threshold Values and Diagnostic Criteria

Hemophilia & dosing thresholds — numeric criteria

Hemophilia factor levels (severe/moderate)Severe: factor VIII or IX level <1%; Moderate: 1%–5% (documented in member record)

Inhibitor titer> 5 Bethesda Units/mL (historical or current high titer required for inhibitor-related pathways)

Prednisone/prednisolone adequate dosing0.75 mg/kg/day required trial dose before approving Agamree for DMD

High-dose hemophilia dosing reviewRequests for doses >150 mg weekly require consultation with a BCBS medical director (gene therapy discussion)

Initial approval durations (hemophilia examples)Hemlibra: initial approval 1 year; some hemophilia B prophylaxis entries: initial approval 6 months

BMI, age, platelet, eosinophil and weight thresholds

Adult BMI threshold for weight-management agentsBMI ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 with at least one weight-related comorbidity (e.g., HTN, T2DM, dyslipidemia)

Pediatric obesity thresholdBMI ≥ 95th percentile for age and sex (applies for adolescents 12–17 for some agents)

Platelet count thresholds for thrombopoietic agentsPersistent platelet count <100,000/mcL for ≥3 months; acute criteria: current platelets <20,000 mcL or <30,000 mcL with bleeding; renewal target 50,000–200,000/mcL

Eosinophil thresholdsEosinophils ≥150 cells/µL at initiation for some asthma indications; ≥300 cells/µL used as evidence of type 2 inflammation for COPD in some criteria

Weight minimums for select productsEbglyss requires weight ≥40 kg; Furoscix outpatient use requires patient weight ≥43 kg

Specialty lab/genetic thresholds (PNH, HAE, obesity genetics, NASH, hyponatremia)

PNH LDH threshold (high disease activity)LDH ≥ 1.5 times the upper limit of normal (with associated symptoms) for PNH treatment consideration

HAE laboratory confirmationC4 below lab normal range (normal range cited as 16–58 mg/dL) AND C1INH antigenic or functional level below lab normal (normal function ≥41%)

Imcivree obesity definitionsAdults: BMI ≥ 30 kg/m2; Pediatrics: BMI ≥ 95th percentile for age/sex; current weight and BMI within 30 days must be submitted

NASH/MASH fibrosis stage requirementAdvanced fibrosis defined as fibrosis stage F2 to F3 verified by FibroScan or other noninvasive assessment

Samsca serum sodium thresholdSerum sodium <125 mEq/L for clinically significant hyponatremia indication

Administration, Dispensing and Benefit Routing

Documentation Required

Office, infusion center, and hemophilia treatment center requirements

Office, infusion center, and hemophilia treatment center requirements are specified for many products; oncology pharmacy‑benefit drugs use the OncoHealth pathway submitted via Availity.

Hemophilia products: must be prescribed/dispensed by a specialist at an accredited hemophilia treatment center.
Oncology/supportive care pharmacy drugs: PA via OncoHealth (Availity).

Topical testosterone products and certain acute migraine agents include site-of-care and benefit-split implications in the drug entries. Topical testosterone (e.g., Axiron, Fortesta) coverage requires a documented diagnosis of male hypogonadism and two signs/symptoms of testosterone deficiency; some topical product/strength combinations are explicitly marked NC for certain benefit categories, so coverage and member cost liability depend on the plan and formulation selected.

Examples of site-of-care and dispensing notes: products generally administered in a provider’s office or infusion center may be managed under the medical benefit rather than the pharmacy benefit (refer to the Blue Cross/BCN Utilization Management Medical Drug List). For acute migraine, Ubrelvy requires age ≥18 and documented failure or contraindication to two generic triptans before pharmacy coverage is approved; prescribers should confirm benefit coverage (pharmacy vs medical) and obtain prior authorization when required to avoid out-of-pocket risk.

When in doubt about whether a medication is processed under the pharmacy or medical benefit (or which formulation/strength is NC), consult the plan’s drug matrix and the Utilization Management Medical Drug List prior to ordering or dispensing.

Preferred Biosimilars and Impact on Step Lists

Step Therapy

Preferred adalimumab/ustekinumab biosimilars required as prior agents

Step lists and Entyvio/Orencia criteria reference preferred biosimilars — providers should trial preferred adalimumab and preferred ustekinumab biosimilars when they are listed as required prior agents.

Entyvio/Orencia step criteria include preferred adalimumab biosimilar and preferred ustekinumab biosimilar among required prior agents.

Definitions and Background

Prior authorization and step therapy are utilization management tools that require documentation before the plan will pay for certain medications. Prior authorization is a review required when drugs have safety risks, limited indications, potential for misuse, or are high-cost specialty agents; approvals typically specify an initial authorization length (commonly 1 year but can be shorter, e.g., 60 days or 3 months) and require renewal with evidence of ongoing clinical benefit.

Step therapy requires that one or more preferred or generic alternatives be tried and found ineffective, intolerable, or contraindicated before a non-preferred or higher-cost therapy will be approved. Each drug entry lists the exact prior agents, number of required trials, and any age/weight/laboratory thresholds that must be documented (for example, trials of two different-class migraine preventive medications before CGRP antibodies are authorized, or multiple generic antiepileptic failures before coverage of certain branded antiseizure formulations).

Failure to obtain required prior authorization or to document mandated step-therapy trials may result in denial of coverage or the member being responsible for the full cost (NC). Providers should follow the drug-specific authorization instructions and submit required diagnostic, laboratory, and prior-treatment documentation to avoid coverage denials.

Short definitions and key terms

Prior authorizationA review required for certain medications before the plan will cover them; approvals commonly last one year and ensure preferred alternatives have been tried

Step therapyRequirement to try one or more preferred drugs before coverage of a more expensive alternative is approved

DMARDDisease Modifying Anti-Rheumatic Drug (examples: methotrexate, hydroxychloroquine, leflunomide, sulfasalazine)

Hemophilia treatment centerSpecialized center that prescribes/dispenses hemophilia products and is required for certain hemophilia coverage pathways

ATTR-CMTransthyretin-mediated amyloidosis with cardiomyopathy confirmed by negative monoclonal light chain screen plus technetium-labeled bone scintigraphy or endomyocardial biopsy

Policy Changes and Document Revisions

2026-04-01document_revisionLatest

Document revised (header shows 'Revised: 04-01-2026').

2026-03-01policy_publish

New coverage criteria published for multiple drugs (e.g., topiramate solution [Eprontia], Camzyos, Furoscix, Fabhalta, Lupkynis).

2026-05-01policy_effective_date

New coverage criteria for listed drugs become effective (examples include Eprontia, Camzyos, Furoscix, Fabhalta, Lupkynis effective 05-01-2026).

Note

Material change summary — new criteria published 3/1/2026 (effective 5/1/2026)

Material coverage changes: new coverage criteria published 3/1/2026 with effective date 5/1/2026 for selected drugs including topiramate solution (Eprontia), Camzyos, Furoscix, Fabhalta, and Lupkynis — providers should use the updated criteria effective 5/1/2026.

Publish date of new coverage criteria: 3/1/2026; Effective date: 5/1/2026 for listed updated drug entries.