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Expansion of Medicare Part B Step Therapy and Prior Authorization Requirements
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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