CommercialPrior AuthMedium impact
Mirikizumab-mrkz (Omvoh)
BCBS Tennessee·TN · Gastroenterology·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
BlueCross BlueShield of Tennessee is establishing a new medical policy for Mirikizumab-mrkz (Omvoh), a biologic medication for moderately to severely active ulcerative colitis and Crohn's disease in adults. The policy requires prior authorization, gastroenterologist prescription/consultation, TB screening before initiation, and documented clinical response for continuation. Step therapy may apply per a separate guide.
Action Required
By November 1, 2026: (1) Billing team must configure prior authorization requirement in billing system for Mirikizumab-mrkz (Omvoh) claims for BlueCross BlueShield of Tennessee members. (2) Update prior auth submission requirements to mandate: diagnosis confirmation (UC or CD), documentation of moderate-to-severe disease activity, gastroenterologist involvement verification, and TB screening documentation. (3) For continuation requests, require submission of chart notes showing positive clinical response, remission achievement, or improvement in specified clinical markers (stool frequency, rectal bleeding, CRP, fecal calprotectin, endoscopy findings, disease activity scores, etc.). (4) Implement system edits to prevent simultaneous billing of Mirikizumab with other biologic or targeted synthetic drugs for the same indication. (5) Train provider relations and authorization staff on step therapy requirements per the referenced BC PAD Step Therapy Guide. (6) Communicate policy to gastroenterologists and relevant providers. Claims submitted without prior authorization or missing required documentation will be denied.