All PlansPrior AuthMedium impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Pharmacy, Oncology, Endocrinology +1 more·Pharmacy
Effective date
Sep 13, 2026
We identified it
Aug 27, 2026
Summary
This pharmacy policy update adds new drugs to formulary criteria, expands coverage for existing medications based on recent FDA label updates, and removes or streamlines prior authorization requirements for specific drugs. Key changes include: adding tapentadol oral solution and new Sarclisa formulation to formulary, removing venetocax trial requirement for Jaypirca (CLL/SLL), eliminating documentation requirements for Arikayce, and significantly expanding Tzield criteria for type 1 diabetes prevention/treatment across broader age groups and serotypes for myasthenia gravis treatments (Vyvgard, Vybgart Hytrulo). Two effective dates apply: 09/13/2026 and 11/04/2026.
Action Required
By September 13, 2026: Pharmacy billing team must update prior authorization criteria in the billing/formulary management system for all affected drugs. Specifically: (1) Add tapentadol oral solution to criteria and limit chart in formulary database; (2) Add Sarclisa Escena (isatuximab-irfc) subcutaneous formulation to Essential tier criteria; (3) Remove venetocax pretreatment requirement for Jaypirca (CLL/SLL indication) in PA system; (4) Remove all documentation requirements for Arikayce in PA workflows. By November 4, 2026: Update criteria for Tzield to include patients age 1+ (previously restricted), align dysglycemia testing to ADA guidelines, exclude type 2 diabetes patients, add age <45 restriction for Stage 3 onset delay, remove 6-month autoantibody test requirement, and add new Stage 3 recently-diagnosed criteria. Update Vyvgard/Vybgart Hytrulo to require prescriber specialty verification, prohibit concurrent Uplizna use for myasthenia gravis, set initial approval duration to 12 months, and expand approval to all myasthenia gravis serotypes. Notify providers of relaxed requirements to reduce claim denials. Update all PA denial rules and approval templates accordingly. Coordinate with clinical staff to ensure EMR/EHR systems reflect new clinical criteria for these conditions.