CommercialPrior AuthMedium impact
Adakveo (crizanlizumab-tmca)
Blue Cross & Blue Shield of Mississippi·MS · Hematology, Oncology·Medical Policy
We identified it
Jun 20, 2026
Summary
BCBSMS updated their Adakveo (crizanlizumab-tmca) policy for sickle cell disease treatment, requiring prior authorization with specific criteria including age 16+, documented sickle cell disease, at least 2 pain crises in 12 months, and either current hydroxyurea use or contraindication to hydroxyurea. Services related to delivery/administration without approved prior authorization will be considered not medically necessary.
Action Required
Immediately: Billing team must ensure prior authorization is obtained for all Adakveo (crizanlizumab-tmca) prescriptions using HCPCS code J0791 before billing BCBSMS. Verify patients meet all criteria: age 16+, documented sickle cell disease, 2+ pain crises in past 12 months, and hydroxyurea status. Claims for delivery/administration services without approved prior auth will be denied as not medically necessary.