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Blue Cross & Blue Shield of MississippiCommercial · Coverage · Medical Policy · MS · Dermatology, Wound CareMedium impact

State and School Employees' Health Insurance Plan - Treatment of Epidermolysis Bullosa

Effective date
Not stated in the notice
Identified
Jun 20, 2026

Summary

Vyjuvek (beremagene geperpavec-svdt) may be considered medically necessary for dystrophic epidermolysis bullosa when the individual has a documented diagnosis, chart notes and laboratory values confirming a COL7A1 gene mutation, blistering wounds or scarring, and at least one recurrent or chronic open wound that meets the wound criteria. The policy criteria were revised to remove the age requirement, and that revision is dated 05/26/2026. Renewal requires prior approval through the BCBSMS review process, documented clinical improvement, and continued wound and prescriber criteria, with approval for 6 months.

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What to do

Action · 9 steps
01Billing team: Search the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting before submitting a Vyjuvek request.
02Confirm the record includes clinic chart notes and laboratory values confirming a mutation in the COL7A1 gene, a documented diagnosis of dystrophic epidermolysis bullosa, and blistering wounds or scarring.
03Confirm the wound meets all criteria: adequate granulation tissue, excellent vascularization, no evidence of active wound infection, no evidence of history of squamous cell carcinoma, and no recent skin graft within the past 3 months.
04Confirm the prescriber is a specialist or has consulted a dermatologist with expertise in treating DEB, that the individual has no FDA-labeled contraindication, and that the dose is within program quantity limits based on FDA labeled dosage.
05Approval length is 6 months.
06For renewal, confirm the individual was previously approved through the BCBSMS review process and has documented clinical improvement, such as decrease in wound size, increase in granulation tissue, or complete wound closure.
07Medical records must contain all specific information needed for a medical necessity determination, because letters of support alone are not sufficient.
08Use of samples will not be considered current or stable therapy.
09Services related to delivery or administration of a medication determined not medically necessary will also be considered not medically necessary.

Codes mentioned

C9399J3401J3490J3590Q81.2

Original notice

State and School Employees' Health Insurance Plan - Treatment of Epidermolysis Bullosa
bcbsms.com · Always check the source before changing claims.
View original ↗

Related changes

See all Blue Cross & Blue Shield of Mississippi changes →
Treatment of Epidermolysis BullosaHighEffective Jan 1, 2025 · Medical PolicyState and School Employees' Health Insurance Plan - Palynziq (pegvaliase-pqpz)MediumNo effective date · Medical PolicyPalynziq (pegvaliase-pqpz)MediumNo effective date · Medical PolicyState and School Employees' Health Insurance Plan - Injectable OncologyMediumNo effective date · Medical PolicyBrowse every Blue Cross & Blue Shield of Mississippi change in the policy list

Related policy hubs

Blue Cross & Blue Shield of Mississippi policiesMS policy changesDermatologyWound CareCode C9399Code J3401Code J3490Code J3590Code Q81.2

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