CommercialPrior AuthMedium impact
Vedolizumab (Entyvio®)
BCBS Tennessee·TN · Gastroenterology, Hematology, Oncology·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
BlueCross BlueShield of Tennessee has issued a new medical policy for Vedolizumab (Entyvio®) effective December 1, 2026, establishing coverage criteria for four indications: moderately to severely active ulcerative colitis and Crohn's disease (12-month authorization), immune checkpoint inhibitor-related toxicity (6-month authorization), acute graft versus host disease (12-month authorization), and CAR T-cell-related toxicity (6-month authorization). The policy requires prior authorization, specific prescriber specialties, detailed documentation of clinical response for continuation, and prohibits concomitant use with other biologic or targeted synthetic drugs for the same indication.
Action Required
By December 1, 2026: (1) Billing team must configure prior authorization workflow in billing system to require authorization before processing Vedolizumab claims for UC, CD, immune checkpoint inhibitor-related toxicity, acute graft versus host disease, and CAR T-cell-related toxicity. (2) Update claim submission protocols to verify prescriber specialty matches policy requirements (gastroenterologist for UC/CD; gastroenterologist/hematologist/oncologist for other indications). (3) Implement documentation requirements: for UC/CD continuation, require chart notes showing clinical response/remission; for other indications, require documentation of prior medication trials and response or clinical reason to avoid. (4) Configure system edits to flag claims with concomitant biologic/targeted synthetic drug use for the same indication and deny accordingly. (5) Update prior authorization request forms to include disease activity assessment parameters (stool frequency, CRP, fecal calprotectin, endoscopy findings, disease activity scores per indication). (6) Train billing and authorization staff on coverage criteria thresholds (6-month vs. 12-month authorizations by indication). Claims submitted without prior authorization or failing to meet documented criteria will be denied.