CommercialPrior AuthHigh impact
Policy Criteria Change
Arkansas Blue Cross Blue Shield·AR · Gastroenterology, Rheumatology, Internal Medicine·Medical Policy
Effective date
Oct 28, 2026
We identified it
Aug 25, 2026
Summary
Arkansas Blue Cross updated approval criteria for four biologic medications used to treat Crohn's disease and ulcerative colitis (Certolizumab pegol, Guselkumab, Mirikizumab-mrkz, and Infliximab/biosimilars). Key changes include standardized step-therapy requirements, mandatory documentation of conventional therapy trial or contraindication, and strict prohibitions on combination biologic therapy. The policy also adds new off-label coverage for immune-mediated toxicities associated with Infliximab. All changes are effective October 28, 2026.
Action Required
By October 28, 2026: (1) Billing Team - Update prior authorization system to enforce new step-therapy criteria for HCPCS codes J0717 (Certolizumab pegol), J1100 (Guselkumab), J1602 (Mirikizumab-mrkz), and J1745 (Infliximab). Require documented evidence of either ≥3 months trial of conventional therapy (betamethasone, methylprednisolone, prednisolone, prednisone, budesonide, hydrocortisone, azathioprine, mercaptopurine, sulfasalazine, mesalamine, or methotrexate) OR documented contraindication/intolerance to at least one conventional agent before approving initial claims. (2) Providers/Clinical Staff - Update EMR templates to capture: age verification (≥18 years for newer agents; ≥6 years for Infliximab), disease severity documentation (moderate to severe), prior biologic/JAK inhibitor history, high-risk disease features per ACG 2025 guidelines, and current medications to verify NO concurrent use of other biologics (TNF inhibitors, IL-36 inhibitors, integrin inhibitors, IL inhibitors, PDE4 inhibitors, or JAK inhibitors). (3) Prior Authorization Reviewers - Flag any claims combining this biologic with another biologic agent for automatic denial. (4) Billing Team - For off-label Infliximab claims (colitis, pneumonitis, enterocolitis), implement separate authorization workflow with enhanced documentation requirements. Failure to obtain proper prior authorization or submit required documentation will result in claim denials and possible patient balance billing.