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Medical Policy and Coding Updates - October 2025
Premera Blue Cross·WA · Rheumatology, Gastroenterology, Dermatology +5 more·Medical Policy
Effective date
Jan 2, 2026
We identified it
Jun 16, 2026
Summary
Premera Blue Cross updated medical necessity criteria and preferred drug formularies across multiple therapeutic areas, with major changes to preferred status for biosimilar medications including adalimumab, infliximab, and rituximab products. Most changes require step therapy with preferred products before accessing non-preferred alternatives.
Action Required
By January 2, 2026: Update prior authorization protocols for specialty medications across multiple therapeutic areas. Billing team must verify preferred drug status in system for adalimumab products (Yuflyma now preferred, Cyltezo now non-preferred), infliximab products (Avsola now preferred, Remicade/Janssen require step therapy), and rituximab products (Riabni now preferred, Rituxan requires step therapy). Update encounter forms to remind providers of new step therapy requirements. Claims for non-preferred products will be denied without documentation of inadequate response to preferred alternatives.