All PlansCoverageMedium impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Nephrology, Pediatrics, Pharmacy·Pharmacy
Effective date
Aug 10, 2026
We identified it
Jul 21, 2026
Summary
This policy updates coverage criteria for two specialty drugs: Fabhalta now requires a lower urine protein-to-creatinine ratio (UPCR) threshold of 0.5 g/g for IgAN patients (down from 0.8 g/g) with expanded continuation criteria, and Hympavzi coverage is extended to pediatric patients ages 6+ (removing the 35 kg weight requirement). Both changes are effective 8/10/2026.
Action Required
By August 10, 2026: Billing and prior authorization teams must update pharmacy benefit management (PBM) systems and prior authorization workflows to reflect the new UPCR threshold of 0.5 g/g for Fabhalta IgAN claims and remove weight-based restrictions for Hympavzi in pediatric patients age 6+. Update clinical review criteria and decision trees in the authorization system. Coordinate with providers in nephrology and pediatrics practices to communicate the new eligibility criteria. Failure to update authorization rules may result in inappropriate claim denials for otherwise eligible patients.