CommercialCoverageMedium impact
State and School Employees' Health Insurance Plan - Palynziq (pegvaliase-pqpz)
Blue Cross & Blue Shield of Mississippi·MS · Endocrinology, Pediatrics, Family Medicine·Medical Policy
Effective date
Jun 3, 2025
We identified it
Jun 20, 2026
Summary
Updated medical policy for Palynziq (pegvaliase-pqpz) for PKU treatment now explicitly states that drug samples cannot be used to satisfy medical policy requirements for therapy history. The policy also clarified criteria for initial evaluation and renewal, requiring failed sapropterin trial and enrollment in REMS program.
Action Required
By June 3, 2025: Billing team must update prior authorization processes for Palynziq (pegvaliase-pqpz) to ensure drug samples are not documented as satisfying therapy requirements. Verify all PKU patients have documented failed sapropterin trial and REMS program enrollment before submitting claims. Update documentation requirements to include epinephrine prescription verification.