CommercialPrior AuthMedium impact
BlueSpeak October 2026: Pharmacy Policy Updates
Blue Cross and Blue Shield of Kansas City·MO · Hematology, Oncology, Infectious Disease +2 more·Pharmacy
Effective date
Nov 1, 2026
We identified it
Oct 27, 2026
Summary
Blue KC is implementing pharmacy policy updates effective November 1, 2026, including one new prior authorization policy for Tregzi (allogeneic regulatory T cell immunotherapy) and updates to 11 existing prior authorization policies for specialty medications across hematology, rare disease, and immunology treatments. Billing and authorization teams must update systems to reflect new coverage criteria and drug additions for affected medications.
Action Required
By November 1, 2026: (1) Billing team and authorization staff should update prior authorization protocols in the billing system for Policy 5.02.700 (Tregzi - new prior auth requirement) and Policies 5.02.527, 5.02.683, 5.02.665, 5.02.543, 5.02.564, 5.02.625, 5.02.609, 5.02.666, 5.02.682, 5.02.544, and 5.02.576 (updated prior auth criteria aligned with Highmark clinical standards). (2) Update medication formularies and decision support tools to reflect: new drug Avlayah added to Elaprase policy (5.02.527); new indication for warm autoimmune hemolytic anemia under Imaavy (5.02.683); updated coverage criteria for Anktiva, Brineura, Evenity, Korsuva, Nulibry, Parenteral Iron, Qfitlia, Radicava, and Trodelvy policies. (3) Notify providers and front-desk staff that prior authorization is required for Tregzi (IV, medical benefit for hematological malignancies). These updates apply to Commercial, ACA QHP, Small Group, ACA JAA, FEP, and Medicare Advantage (BlueCard) lines of business. Failure to implement prior auth requirements may result in claim denials.