Summary
Independence Blue Cross expanded Evkeeza (evinacumab-dgnb) coverage for homozygous familial hypercholesterolemia to include children aged 1 year or older (previously 5 years), lowered the untreated LDL-C threshold from 500 mg/dL to 400 mg/dL, and removed prior requirements for treated LDL-C levels and parental cholesterol documentation. These changes are effective 11/02/2026.
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What to do
Action · 8 steps
01Effective 11/02/2026: Update charge entry and prior authorization tracking to reflect the new coverage criteria for evinacumab-dgnb (J1305).
02Billing team should.
03Verify that prior authorization requests for patients aged 1 to less than 10 years include documentation of untreated LDL-C ≥130 mg/dL (or ≥100 mg/dL if additional risk factors present) rather than prior therapy requirements.
04For patients aged 10 years and older, confirm prior auth requests document LDL-C ≥100 mg/dL and concurrent use of maximally tolerated high-intensity statin, ezetimibe, and PCSK9 inhibitor (unless two LDLR-negative alleles).
05Remove documentation requirements for treated LDL-C levels ≥300 mg/dL and parental cholesterol >250 mg/dL from prior authorization templates.
06Ensure continuation therapy requests document at least 30% LDL-C reduction since initiation.
07Tell providers and front desk staff that younger pediatric patients (ages 1–4) are now eligible, and update diagnosis code routing to E78.010 (homozygous familial hypercholesterolemia).
08Claims submitted without meeting the revised criteria will be denied.
Codes mentioned
J1305E78.010
Original notice
08.01.76e, Evinacumab-dgnb (Evkeeza®)
medpolicy.ibx.com · Always check the source before changing claims.
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