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State and School Employees' Health Insurance Plan - Neonatal Fc Receptor Blockers
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Rystiggo (rozanolixizumab-noli) may be considered medically necessary for generalized myasthenia gravis in adults 18 or older who are anti-AChR or anti-MuSK antibody positive, with an MG-ADL total score of 6 or more and documented inadequate response or intolerance to conventional therapy. Vyvgart, Vyvgart Hytrulo, and Imaavy (nipocalimab-aahu) are considered not medically necessary because other formulary alternatives are covered by the plan for those indications. The 06/15/2026 update removed the brand names Soliris and Ultomiris from the policy statements.
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What to do
Action · 9 steps
01Before billing Rystiggo (J9333) for these members, perform a formulary drug search on the member ID to confirm coverage under the member's benefit plan, and submit any required prior authorization.
02For State Health Plan members, search the formulary at https://www.dfa.ms.gov/cvs-caremark and submit prior authorization requests to the Plan's Pharmacy Benefit Manager, because self-administered drugs may be covered under the pharmacy benefit.
03Confirm the chart documents generalized myasthenia gravis with a positive anti-AChR or anti-MuSK antibody, an MGFA class of II-IV, and an MG-ADL score of 6 or more.
04Also confirm one of the following: inadequate response to corticosteroids and at least one immunosuppressive therapy, an FDA-labeled contraindication, intolerance, or hypersensitivity to all conventional agents, or required chronic IVIG or plasmapheresis/plasma exchange.
05The member must not use the drug with a complement inhibitor or another neonatal Fc receptor blocker, and the prescriber must be a specialist (neurologist) or have consulted one.
06Initial approval lasts 6 months.
07Renewal lasts 12 months and requires documented reduction in exacerbations or a 3-point or greater improvement in MG-ADL from baseline.
08Stop billing Vyvgart (J9332), Vyvgart Hytrulo (J9334), and Imaavy (J9256) for these members, because they are considered not medically necessary as other formulary alternatives are covered.
09Code C9305 was deleted 12/31/2025, and J9256 is new as of 01/01/2026.
Codes mentioned
J9333G70.00G70.01C9305J9256J9332J9334
Original notice
State and School Employees' Health Insurance Plan - Neonatal Fc Receptor Blockers
bcbsms.com · Always check the source before changing claims.