CommercialPrior AuthMedium impact
State and School Employees' Health Insurance Plan - Krystexxa (pegloticase)
Blue Cross & Blue Shield of Mississippi·MS · Rheumatology, Nephrology, Internal Medicine·Medical Policy
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
This is a new medical policy for Krystexxa (pegloticase) coverage for chronic gout treatment under the State and School Employees' Health Insurance Plan. The policy establishes strict criteria including failed trials of multiple medications, specialist involvement, and administration in healthcare settings with anaphylaxis management capabilities.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements for HCPCS code J2507 (pegloticase injection). Update billing system to flag this code for prior auth verification. Ensure claims include documentation of failed allopurinol and febuxostat/probenecid trials, specialist consultation, and administration in appropriate healthcare setting. Claims without proper authorization will be denied.