Summary
BlueCross BlueShield of Tennessee is implementing a new prior authorization requirement and coverage policy for Velaglucerase Alfa (VPRIV®), an enzyme replacement therapy for Gaucher disease types 1, 2, and 3. The policy requires step therapy, specialized prescriber credentials, baseline diagnostic testing, and clinical evidence of disease before initial approval; continuation therapy requires documented clinical benefit. This policy becomes effective October 31, 2026, and applies to all Tennessee members.
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What to do
Action · 7 steps
01Before October 31, 2026.
02Billing team must implement prior authorization requirement in billing system for VPRIV (J3398) using the BlueCross BlueShield of Tennessee Step Therapy Guide (https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf).
03Update encounter forms and provider workflows to require: Beta-glucocerebrosidase enzyme assay or genetic testing results, documentation of baseline clinical signs/symptoms (bone disease, splenomegaly, hepatomegaly, cytopenia), and verification that prescriber is a metabolic disease or lysosomal storage disorder specialist.
04For continuation requests, ensure documentation of clinical benefit (improvement in liver/spleen volume, hemoglobin, or platelet count) is captured and submitted.
05Configure system to limit dosing to 60 units/kg IV every 2 weeks.
06Create prior auth submission checklist for providers.
07Providers must verify that all documentation requirements are met before submitting claims.
If missed: Failure to obtain prior authorization or submit required documentation will result in claim denials.
Codes mentioned
J3398
Original notice
Velaglucerase Alfa (VPRIV®)
bcbst.com · Always check the source before changing claims.