Expansion of Medicare Part B Step Therapy and Prior Authorization Requirements

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Expansion of Medicare Part B Step Therapy and Prior Authorization Requirements

January 11, 2023

Pharmacy Blue Medicare

Effective February 6, 2022, Blue Cross NC Medicare Advantage is expanding Medicare Part B Step Therapy and Prior Authorization requirements for medications listed below. Prior Authorization will address medical necessity, while Step Therapy focuses on the use of safe, lower-cost alternatives. Please note, Step Therapy program requirements will only apply to patients new to these medications; current users will not be impacted.

What do I need to do?

Please review these new requirements for Medicare Part B. On or after February 6, 2022, you will need to provide additional information to Blue Cross NC. For faster service, submit requests to Blue Cross NC electronically via CoverMyMeds™ , our free online prior authorization tool.  If you do not have online access, you can submit requests via fax or phone to the numbers listed at the top of the drug-specific fax form.

HCPCS Code	Medication Name	Requirement	Effective Date
J2786	Cinqair (reslizumab) injection	Step Therapy	01/01/2019
J0517	Fasenra (benralizumab) injection	Step Therapy	12/01/2019
J2182	Nucala (mepolizumab) injection	Step Therapy	01/01/2019
J2356	Tezspire (tezepelumab-ekko) injection	Step Therapy	02/06/2023
J2357	Xolair (omalizumab) injection	Step Therapy	01/01/2019
J0179	Beovu (brolucizumab-dbll) intravitreal	Step Therapy	10/01/2021
Q5124	Byooviz (ranibizumab-nuna) intravitreal	Step Therapy	02/06/2023
J0178	Eylea (aflibercept) intravitreal	Step Therapy	01/01/2019
J2778	Lucentis (ranibizumab) intravitreal	Step Therapy	01/01/2019
J2779	Susvimo (ranibizumab) intravitreal	Step Therapy	02/06/2023
J2777	Vabysmo (faricimab-svoa) intravitreal	Step Therapy	02/06/2023
J0202	Lemtrada (alemtuzumab) injection	Step Therapy	06/01/2019
J2350	Ocrevus (ocrelizumab) injection	Step Therapy	06/01/2019
J2323	Tysabri (natalizumab) injection	Step Therapy	06/01/2019
J7318	Durolane (hyaluronate sodium) injection	Step Therapy	02/06/2023
J7323	Euflexxa (hyaluronate sodium) injection	Step Therapy	06/01/2019
J7326	Gel-One (hyaluronate sodium) injection	Step Therapy	06/01/2019
J7328	Gelsyn-3 (hyaluronate sodium) injection	Step Therapy	02/06/2023
J7320	GenVisc 850 (hyaluronate sodium) injection	Step Therapy	06/01/2019
J7321	Hyalgan (hyaluronate sodium) injection	Step Therapy	06/01/2019
J7322	Hymovis (hyaluronate acid) injection	Step Therapy	06/01/2019
J7327	Monovisc (hyaluronate acid) injection	Step Therapy	06/01/2019
J7321	Supartz FX (hyaluronate sodium) injection	Step Therapy	06/01/2019
J7332	Triluron (hyaluronate sodium) injection	Step Therapy	04/04/2022
J7329	TriVisc (hyaluronate sodium) injection	Step Therapy	06/01/2019
J7321	Visco-3 (hyaluronate sodium) injection	Step Therapy	06/01/2019
J1439	Injectafer (ferric carboxymaltose) intravenous**	Step Therapy	10/01/2021
J1437	Monoferric (ferric derisomaltose) intravenous**	Step Therapy	10/01/2021
Q5125	Alymsys (bevacizumab-maly) injection	Step Therapy	10/03/2022
J9035	Avastin (bevacizumab) injection	Step Therapy	10/03/2022
Q5107	Mvasi (bevacizumab-awwb) injection	Prior Authorization	10/03/2022
Q5118	Zirabev (bevacizumab-bvzr) injection	Prior Authorization	10/03/2022
J9355	Herceptin (trastuzumab) injection	Step Therapy	10/03/2022
J9356	Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)	Step Therapy	10/03/2022
Q5113	Herzuma (trastuzumab-pkrb) injection	Step Therapy	10/03/2022
Q5117	Kanjinti (trastuzumab-anns) injection	Prior Authorization	10/03/2022
Q5114	Ogivri (trastuzumab-dkst) injection	Prior Authorization	10/03/2022
Q5112	Ontruzant (trastuzumab-dttb) injection	Step Therapy	10/03/2022
Q5116	Trazimera (trastuzumab-qyyp) injection	Step Therapy	10/03/2022
Q5123	Riabni (rituximab-arrx) injection	Step Therapy	10/03/2022
J9312	Rituxan (rituximab) injection	Step Therapy	10/03/2022
J9311	Rituxan Hycela (rituximab and hyaluronidase) injection	Step Therapy	10/03/2022
Q5119	Ruxience (rituximab-pvvr) injection	Prior Authorization	10/03/2022
Q5115	Truxima (rituximab-abbs) injection	Prior Authorization	10/03/2022
Q5108	Fulphila (pegfilgrastim-jmdb) injection	Step Therapy	10/03/2022
J2506	Neulasta, Neulasta OnPro (pegfilgrastim) injection	Step Therapy	10/03/2022
Q5122	Nyvepria (pegfilgrastim-apgf) injection	Step Therapy	10/03/2022
Q5111	Udenyca (pegfilgrastim-cbqv) injection	Prior Authorization	10/03/2022
Q5120	Ziextenzo (pegfilgrastim-bmez) injection	Prior Authorization	10/03/2022
J1447	Granix (tbo-filgrastim) injection	Step Therapy	10/03/2022
J2820	Leukine (sargramostim) injection	Prior Authorization	10/03/2022
J1442	Neupogen (filgrastim) injection	Step Therapy	10/03/2022
Q5110	Nivestym (filgrastim-aafi) injection	Prior Authorization	10/03/2022
Q5125	Releuko (filgrastim-ayow) injection	Step Therapy	10/03/2022
Q5101	Zarxio (filgrastim-sndz) injection	Prior Authorization	10/03/2022
TBD	Empaveli (pegcetacoplan) subcutaneous infusion	Prior Authorization	10/03/2022
TBD	Enspryng (satralizumab-mwge)	Prior Authorization	10/03/2022
J1300	Soliris (eculizumab) injection	Step Therapy	10/03/2022
J1303	Ultomiris (ravulizumab-cwvz) intravenous (IV)	Prior Authorization	10/03/2022
J1823	Uplizna (inebilizumab-cdon) intravenous (IV)	Prior Authorization	10/03/2022
J9332	Vyvgart (efgartigimod alfa-fcab) intravenous (IV)	Prior Authorization	10/03/2022
J2507	Krystexxa (pegloticase) injection	Prior Authorization	10/03/2022
J3241	Tepezza (teprotumumab-trbw) intavenous (IV)	Prior Authorization	10/03/2022
J0896	Reblozyl (luspatercept-aamt) injection	Prior Authorization	10/03/2022
J1554 J1559	Asceniv (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1556 J1599	Bivigam (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1566 J1599	Carimune NF (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1551	Cutaquig (immune globulin) subcutaneous (SC)	Prior Authorization	10/03/2022
J1555	Cuvitru (immune globulin) subcutaneous (SC)	Prior Authorization	10/03/2022
J1572 J1599	Flebogamma (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1569 J1599	Gammagard Liquid (immune globulin) intravenous (IV) or subcutaneous (SC)	Prior Authorization	10/03/2022
J1569 J1566 J1599	Gammagard S/D (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1569 J1599	Gammaked (immune globulin) intravenous (IV) or subcutaneous (SC)	Prior Authorization	10/03/2022
J1557 J1599	Gammaplex (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1561 J1599	Gamunex-C (immune globulin) intravenous (IV) or subcutaneous (SC)	Prior Authorization	10/03/2022
J1559	Hizentra (immune globulin) subcutaneous (SC)	Prior Authorization	10/03/2022
J1575	HyQvia (immune globulin) subcutaneous (SC)	Prior Authorization	10/03/2022
J1568 J1599	Octagam (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
TBD J1599	Panzyga (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1459 J1599	Privigen (immune globulin) intravenous (IV)	Prior Authorization	10/03/2022
J1558	Xembify (immune globulin) subcutaneous (SC)	Prior Authorization	10/03/2022
Q5121	Avsola (infliximab-axxq) intravenous (IV)	Prior Authorization	02/06/2023
Q5103	Inflectra (infliximab-dyyb) intravenous (IV)	Prior Authorization	02/06/2023
J1745	Remicade (infliximab) intravenous (IV)	Step Therapy	02/06/2023
Q5104	Renflexis (infliximab-abda) intravenous (IV)	Step Therapy	02/06/2023

*This list is subject to change.

**These products do not require review for patients on dialysis when submitted for reimbursement as part of the End Stage Renal Disease (ESRD) Prospective Payment System (PPS), or “bundled” PPS amount.

Please be aware that if prior plan approval for these medications is not given by Blue Cross NC Medicare Advantage, the service(s) may not be covered under the member’s Medicare Advantage plan, and the provider may be responsible for the entire cost of the drug and associated service(s). Providers cannot bill members for services when prior plan approval is required but the provider failed to obtain the request prior to rendering services.  Additionally, if the member changes Blue Cross NC Medicare Advantage policies, you may need to certify they have met our medical necessity criteria under the new policy for the medication(s) in question.

Please note this may not be a comprehensive list. Visit the Medicare Providers Prior Plan Approval page for more information.

How can I learn more?

If you have questions, please call our Provider Blue Medicare line at 888-296-9790 for assistance.

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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