CommercialCoverageHigh impact
State and School Employees' Health Insurance Plan - Anti-Rheumatic Biologicals
Blue Cross & Blue Shield of Mississippi·MS · Rheumatology·Medical Policy
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
The State and School Employees' Health Insurance Plan updated coverage for anti-rheumatic biologicals effective January 1, 2025, removing coverage for Actemra, Avsola, Renflexis, and Tofidence while adding coverage for Inflectra, Tyenne IV, and Cosentyx IV for specific conditions. The policy requires specialist involvement and conventional therapy failure before biologic approval.
Action Required
Immediately: Update billing system to reflect that HCPCS codes J3262, Q5121, and Q5133 are no longer covered for State and School Employees' plan members. Add new covered codes Q5103, Q5135, and J3247 to formulary lists. Ensure prior authorization requests include specialist consultation documentation and evidence of conventional therapy failure for all biologic requests. Train staff on updated coverage criteria requiring 3 consecutive months of DMARD therapy before biologic approval.