CommercialPrior AuthMedium impact
State and School Employees' Health Insurance Plan - Alpha-1 Proteinase Inhibitors
Blue Cross & Blue Shield of Mississippi·MS · Pulmonology·Medical Policy
We identified it
Jun 20, 2026
Summary
Blue Cross Blue Shield of Mississippi updated their policy for Alpha-1 proteinase inhibitor treatments (Aralast NP, Glassia, Prolastin-C, Zemaira) with revised medical necessity criteria including new age requirements, genotype exclusions, and lung function parameters. The policy clarifies that drug samples cannot be used to satisfy therapy requirements and requires specialist involvement for coverage approval.
Action Required
Immediately: Update prior authorization workflows for Alpha-1 proteinase inhibitor drugs (J0256, J0257) to include new requirements: patient must be 18+ years old, exclude PI*MZ genotype patients, document baseline FEV1 levels, confirm specialist consultation, and verify smoking cessation participation. Ensure drug samples are not counted as current therapy when submitting authorization requests. Claims without meeting all criteria will be denied.