All PlansPrior AuthHigh impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Dermatology, Allergy & Immunology, Psychiatry +2 more·Pharmacy
Effective date
Oct 15, 2026
We identified it
Aug 12, 2026
Summary
This policy expands coverage and adds clinical criteria for two drugs: Auvelity now covers agitation associated with Alzheimer's disease (with PRN use prohibition and new prior authorization documentation requirements), and Dupixent expands Chronic Spontaneous Urticaria coverage to younger ages (≥2 years), adds allergic fungal rhinosinusitis coverage, and implements indication-specific prescriber specialty requirements across all covered indications.
Action Required
Before October 15, 2026: Billing and clinical teams must implement the following: (1) Auvelity: Update prior authorization workflows to require documentation of Alzheimer's disease-related agitation diagnosis, clinical indication, and initial/continuation approval criteria; add system rules to prohibit claims with PRN modifier for Alzheimer's-related agitation indications; educate prescribers on non-covered indications beyond MDD and Alzheimer's disease-related agitation. (2) Dupixent: Update authorization forms to include indication-specific prescriber specialty requirements; implement step therapy rules requiring documentation of inadequate response to up-dosed second-generation antihistamine for CSU cases; add coverage criteria for new indication (Allergic Fungal Rhinosinusitis) with continuation criteria requiring documented positive clinical response; update age eligibility in billing system for CSU from ≥12 years to ≥2 years. Obtain clarification from payer on specific HCPCS/NDC codes if not already mapped. Failure to implement prior auth requirements will result in claim denials. Coordinate with providers on documentation expectations immediately to allow preparation time.