Part B step therapy applies to listed Part B drugs

Step therapy applies to certain Medicare Part B prescription drugs listed in the payer's Part B step therapy chart for Blue Cross Medicare Advantage markets; providers should consult that chart to determine whether a medication is subject to step therapy prior to prescribing.

Drugs enumerated as requiring Part B step therapy

The document lists numerous specific Part B products and product families that are subject to Part B step therapy; this segment provides drug names but does not itself give step mechanics.

Part B drugs in step therapy may require prior authorization

Many Part B drugs included in the step therapy chart (for example colony‑stimulating factors, denosumab products, immune globulins, and other biologics/biosimilars) may require prior authorization or must satisfy step edits before coverage is allowed.

Drug names shown as subject to Part B step therapy (no codes here)

This section of the chart lists drug names that are subject to Part B step therapy but does not list specific HCPCS/CPT codes or step‑edit mechanics within the listing fragments.

Listed Part B drugs subject to step therapy

The payer's step therapy lists specific products (brand and biosimilar names) grouped by drug family; providers must use those lists to identify which agents require step‑first trials.

Denosumab‑class nonpreferred: prior use or exception required

When prescribing a nonpreferred denosumab‑class product, coverage requires meeting step criteria: history of use of one preferred denosumab agent, or documented inability to use the preferred agent due to a formulation (inactive‑ingredient) allergy/serious adverse reaction per the prescriber, or continuation/prior use within the past 365 days.

IVIG: prior use or indication documentation required

Nonpreferred IVIG products commonly require meeting step‑therapy documentation: either disease‑specific indication criteria, history of use of two preferred IVIG products (as specified), or continuation/prior use within the past 365 days for coverage to be allowed.

Prior authorization required for nonpreferred/step agents

Prior authorization is required when prescribing nonpreferred or step‑therapy medications unless an allowed continuation or other listed exception applies; providers must follow the payer's medical prior authorization process.

Step therapy prior‑use requirements for nonpreferred IV/SC agents

Nonpreferred intravenous or subcutaneous Part B agents require meeting the step therapy criteria (history of preferred agent use, clinical indication exceptions, or continuation within 365 days) before Step‑2 agents will be covered.

Viscosupplement step requirement: two preferred trials or continuation

Nonpreferred viscosupplements are subject to step criteria in listed MAC regions: coverage requires documentation of a history of two different preferred viscosupplement medication courses or continuation/use within the past 365 days.

Vyepti: preferred Part D CGRP trial or continuation required

Vyepti coverage requires a history of use of one preferred Part D subcutaneous CGRP inhibitor for migraine prophylaxis, or documentation of continuation/prior use within the past 365 days.

Leqvio: Part D PCSK9 trial plus inadequate efficacy/intolerance or continuation

Leqvio coverage requires prior use of one preferred Part D PCSK9 inhibitor plus documented inadequate efficacy or significant intolerance per the prescriber, or continuation/prior use within the past 365 days.

Use medical prior authorization process for coverage reviews

Medical prior authorization reviews are the pathway for coverage determinations for Part B step‑therapy and nonpreferred agents; providers must submit PA requests per Alacura/Blue Cross procedures.

Submit PA/step therapy requests via payer Provider Manuals/PA code list

Prior authorization or step therapy review requests must be submitted through the Provider Manuals/prior authorization code list URLs provided by the payer (see Provider Manuals and prior authorization code list links).

Reference prescribing information and guidelines for PA support

The step therapy reference materials include prescribing information and clinical guideline citations for immune globulins and immunomodulators; providers should reference these PIs and guidelines when preparing PA requests.

Drug and PI listings included for reference (no PA mechanics provided here)

The document enumerates covered drugs and cites prescribing information for many injectable specialty drugs relevant to step therapy; however these listings do not themselves provide PA forms, codes, or the step mechanics—use them as references only.

Consult cited prescribing information when preparing PA documentation

Product‑specific prescribing information references (e.g., denosumab, eculizumab, IVIG, trastuzumab, viscosupplements) are listed in the policy and should be consulted for dosing, indications, and administration details when completing PA documentation.

Providers must document Step‑1 (preferred) trial before Step‑2 agents

Members must first try preferred medications (Step 1) for specified Part B drug classes; if a preferred medication was tried within the past 365 days or was proven ineffective or intolerable, a nonpreferred agent may be covered under the step therapy rules.

• Preferred agent trial or documented ineffectiveness/intolerance supports escalation to nonpreferred
• Prior trial within 365 days qualifies as recent use

Multiple drug classes/products are included in Part B step therapy

The policy lists many Part B drug classes and specific products as subject to Part B step therapy (for example colony‑stimulating factors, denosumab, IVIGs, rituximab, viscosupplements, among others); providers should review the chart to identify the applicable preferred agents for each class.

Trigger for denial: failure to meet step therapy criteria

Coverage of a nonpreferred medication will be denied if the step therapy criteria are not satisfied (for example, no documented trial of the preferred medication, no documented intolerability/inefficacy, and no continuation within the past 365 days), unless an allowed exception applies.

Sustol/Posfrea may be denied without preferred antiemetic trial

Claims for nonpreferred antiemetic injectables (for example Sustol or Posfrea) may be denied unless the prescriber documents history of use of one preferred injectable antiemetic or documents continuation/prior use within the past 365 days.

Bevacizumab (Avastin/others) denial risk without preferred trial or exception

Nonpreferred bevacizumab reference products may be denied unless the provider documents history of use of a preferred agent, inability to use the preferred agent due to formulation‑related inactive‑ingredient allergy/serious adverse reaction per prescriber, or continuation/prior use within the past 365 days.

Denosumab nonpreferred requests risk denial without step criteria

Requests for nonpreferred denosumab‑class products may be denied unless step‑therapy criteria are met: documented history of one preferred denosumab agent, documented formulation‑based inability to use the preferred agent per prescriber, or continuation/prior use within the past 365 days.

Denosumab/Xgeva nonpreferred requests may be denied without documentation

Requests for nonpreferred denosumab/Xgeva‑group products follow the same denial risk: coverage may be denied unless prior use of a preferred agent, formulation‑based exception, or continuation within 365 days is documented.

Eculizumab nonpreferred requests risk denial without prior‑use documentation

Requests for nonpreferred eculizumab products (e.g., Bkemv, Soliris) may be denied unless the provider documents prior use of the preferred medication, a formulation‑based inability to use the preferred drug, or continuation/prior use within the past 365 days.

IVIG nonpreferred requests may be denied without indications or prior‑use evidence

Nonpreferred IVIG product requests (Alyglo, Asceniv, Bivigam, Panzyga, Qivigy, Yimmugo, etc.) may be denied unless the request meets product‑specific indication criteria, documents history of appropriate preferred IVIG trials (commonly two preferred agents where specified), or documents continuation/prior use within the past 365 days.

Nonpreferred immune globulins risk denial without indication/prior‑use documentation

Nonpreferred immune globulins without meeting listed clinical indications, prior‑use requirements, or continuation criteria may be denied; providers must document indication and prior therapy as specified in the policy.

General denial risk for not meeting step therapy

General step‑therapy denial trigger: coverage may be denied when step therapy conditions are not satisfied for nonpreferred medications (no history of preferred use, no continuation within 365 days, or absence of listed clinical exceptions).

Viscosupplement denials possible without two preferred trials or recent use

Requests for listed nonpreferred viscosupplements may be denied unless the patient has trialed two different preferred viscosupplements or is continuing prior therapy/used the agent within the past 365 days (applies in the MAC regions listed).

Vyepti/Leqvio requests may be denied without Part D preferred‑agent history or continuation

Vyepti or Leqvio requests may be denied if the required Part D preferred‑agent history (Vyepti: one preferred Part D SC CGRP trial; Leqvio: one preferred Part D PCSK9 with inadequate efficacy or intolerance) or continuation criteria (use within past 365 days) are not documented.

Submit PA per payer process or risk non‑compliance

Providers must submit prior authorization requests using the payer's medical prior authorization process; failure to submit PA/step therapy review through the Provider Manuals/PA code list links may result in non‑compliance with PA requirements.

Document prior preferred trial, ineffectiveness/intolerance, or formulation‑based exception

Providers should document prior trial of the preferred medication within the past 365 days, or document ineffectiveness/adverse effects to the preferred agent, or provide a prescriber attestation that the preferred formulation cannot be used due to an inactive‑ingredient allergy/serious adverse reaction to support exceptions.

• Document preferred agent trial within past 365 days when applicable
• Document ineffectiveness or significant adverse reaction to preferred agent
• Prescriber attestation required for formulation‑based exceptions

Use the Part B step therapy list and Provider Manuals when submitting PA

This segment provides lists of drugs subject to Part B step therapy but does not itself specify how to submit documentation; providers must reference the payer's Part B step therapy list and Provider Manuals when preparing coverage or PA requests.