Coverage Exception Policy Updates Effective Sept. 1, 2026

CMS mandates health insurers to maintain a Coverage Exception (CE) process for members with Affordable Care Act (ACA) benefits. This process establishes a protocol by which eligible members may access coverage for non-formulary medications that are not contractually excluded.

Effective Sept. 1, 2026, Blue Cross and Blue Shield of Kansas (BCBSKS) will implement updates to its CE policy. Members must meet the CE criteria to be eligible for approval. Key changes include:

• Before a coverage exception can be approved, members must demonstrate an inadequate response to, or intolerance of both:
  
  • Two generic formulary medications, and
  • Two brand-name formulary medications
• The Continuation of Therapy criterion has been revised.

Please note that members with existing approved Coverage Exception authorizations may continue therapy through the end of their current authorization period. Upon renewal, requests will be evaluated using the updated policy criteria.

We appreciate your continued partnership and support as we implement these updates. Your efforts in helping members navigate benefit and coverage changes are essential to ensuring they receive appropriate and timely access to care. Thank you for your ongoing commitment to the health and well-being of our members.