Summary
Independence Blue Cross updated its Medicare Advantage coverage policy for evinacumab-dgnb (Evkeeza) effective 11/02/2026. The policy expands eligibility by lowering the minimum age from 12 years to 1 year, reducing the untreated LDL-C threshold from 500 mg/dL to 400 mg/dL, and removing requirements for treated LDL-C levels and parental cholesterol documentation. For children ages 1–10, the treatment goal LDL-C is now 130 mg/dL (or 100 mg/dL with additional risk factors), with no prior therapies required.
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What to do
Action · 5 steps
01Effective 11/02/2026, the billing team must.
02Update charge entry and claim submission processes to reflect HCPCS code J1305 (evinacumab-dgnb, 5mg) is now covered for members as young as 1 year of age with homozygous familial hypercholesterolemia (HoFH), with untreated LDL-C greater than 400 mg/dL (previously 500 mg/dL).
03Confirm providers understand the revised clinical criteria: members aged 1 to less than 10 years require LDL-C of 130 mg/dL or greater (lowerable to 100 mg/dL with additional risk factors) and no prior therapies are required; members 10 years and older require LDL-C of 100 mg/dL or greater despite maximally tolerated statin therapy, ezetimibe, and PCSK9 inhibitors for at least 12 weeks.
04Get prior authorization before scheduling or billing J1305 infusions, ensuring documentation includes the HoFH diagnosis (ICD-10: E78.010), current LDL-C level, age, and verification that applicable treatment criteria are met.
05Watch for the payer's next notice regarding continuation therapy requirements and any changes to the pharmacy (Part D) benefit rules for this drug, as this policy addresses only the medical (Part B) benefit.
Codes mentioned
J1305E78.010
Original notice
MA08.133e, Evinacumab-dgnb (Evkeeza®)
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
See all Independence Blue Cross changes →08.01.76e, Evinacumab-dgnb (Evkeeza®)MediumEffective Nov 2, 2026 · PharmacyMA08.133d, Evinacumab-dgnb (Evkeeza®)MediumEffective Oct 1, 2025 · PharmacyMA08.133d, Evinacumab-dgnb (Evkeeza®)MediumEffective Oct 1, 2025 · Pharmacy08.01.76d, Evinacumab-dgnb (Evkeeza®)MediumEffective Oct 1, 2025 · PharmacyBrowse every Independence Blue Cross change in the policy list