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Blue Cross & Blue Shield of MississippiCommercial · Coverage · Medical Policy · MS · Infectious Disease, PharmacyMedium impact

State and School Employees' Health Insurance Plan - Fetroja (cefiderocol sulfate tosylate)

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

Summary

Fetroja (cefiderocol sulfate tosylate) may be considered medically necessary for individuals older than 18 who have complicated urinary tract infection, including pyelonephritis, caused by listed susceptible Gram-negative organisms, or hospital-acquired or ventilator-associated bacterial pneumonia caused by listed susceptible Gram-negative organisms. Coverage requires culture and sensitivity testing that identifies the pathogen and demonstrates susceptibility to the requested medication, with documentation, and requires that the individual has limited or no alternative treatment options and no FDA-labeled contraindication to the requested agent. Length of approval is up to 14 days. The 12/02/2025 update added that the use of samples by an individual will not be considered current or stable therapy.

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What to do

Action · 8 steps
01Billing team should perform a search of the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting.
02Obtain documentation of culture and sensitivity testing that identified the pathogen and demonstrated susceptibility to Fetroja, because the policy requires this documentation.
03Document that the individual has limited or no alternative treatment options and no FDA-labeled contraindication to the requested agent, and that the prescribed dosage is within the program quantity limits based on FDA-approved labeled dosage.
04Samples do not count as current or stable therapy.
05Services related to delivery or administration of a medication determined to be not medically necessary will also be considered not medically necessary.
06BCBSMS may request medical records for determination of medical necessity, and letters of support or explanation are not sufficient unless all specific information needed for the determination is included.
07HCPCS J0699 (Injection, cefiderocol, 10 mg) is listed as a Medically Necessary Code, and the code is only medically necessary if the procedure is performed according to the Policy section.
08The policy states that Fetroja should only be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

Codes mentioned

J0699

Original notice

State and School Employees' Health Insurance Plan - Fetroja (cefiderocol sulfate tosylate)
bcbsms.com · Always check the source before changing claims.
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Related changes

See all Blue Cross & Blue Shield of Mississippi changes →
Fetroja (cefiderocol sulfate tosylate)MediumNo 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 changesInfectious DiseasePharmacyCode J0699

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