Currentblue cross blue shield - michiganPolicy N/A

Medical Drug and Step Therapy Prior Authorization List — Medicare Plus Blue & BCN Advantage

List of medical-benefit drugs that require prior authorization or step therapy for Medicare Plus Blue and BCN Advantage members and instructions for where providers must submit requests.

Policy Summary

Payerblue cross blue shield - michigan

PolicyMedical Drug and Step Therapy Prior Authorization List — Medicare Plus Blue & BCN Advantage

Policy CodePolicy N/A

Change TypeMinor / No material clinical changes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests through the Medical and Pharmacy Drug PA Portal or OncoHealth as specified and include documentation of required step therapy trials when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleDrugs listed with PA or step therapy requirements in this extract

PA PortalPrimary submission channel used for most drugs listed

OncoHealthSubmission channel for oncology and supportive care drugs

20+J‑codes listed in this segment

multipledrugs with step therapy requirements

Coverage and Step Therapy Criteria

Initial coverage and step therapy examples

Coverage requires plan prior authorization and, where specified, completion of step therapy trials

Example - J0129 (Orencia): Prior authorization required; step therapy: trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana. These preferred drugs do not require prior authorization. For members with a MAPD prescription drug plan, trial and failure of adalimumab and Orencia SC is also required. Note: trial and failure of Steqeyma/Pyzchiva/Wezlana is NOT required for rheumatoid arthritis; Orencia SC is not required for aGVHD.

Example - J0177/J0178 (Eylea): Prior authorization required; step therapy: trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar.

Example - J1305/J1306 (Evkeeza/Leqvio): Step therapy: trial and failure of a high‑intensity statin AND Praluent or Repatha before coverage.

Policy Summary

Payerblue cross blue shield - michigan

PolicyMedical Drug and Step Therapy Prior Authorization List — Medicare Plus Blue & BCN Advantage

Policy CodePolicy N/A

Change TypeMinor / No material clinical changes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests through the Medical and Pharmacy Drug PA Portal or OncoHealth as specified and include documentation of required step therapy trials when indicated.

SourceLink

On This Page

Example - J1299/J1303 (Eculizumab/Ultomiris): For specified indications (e.g., myasthenia gravis, NMOSD, PNH, aHUS) prior authorization requires trial and failure of the enumerated alternatives (for example Truxima, Ruxience or Riabni; Vyvgart/Vyvgart Hytrulo; Enspryng; Uplizna; Empaveli; Epysqli) as listed per indication.

Step therapy coverage rules

Covered when the following step therapy requirements are met for the specified drugs:

J2327 (Skyrizi IV): Trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana. For MAPD members, trial and failure of adalimumab is also required. These preferred drugs do not require prior authorization.

J2350/J2329 (Ocrelizumab / Briumvi entries): Trial and failure of dimethyl fumarate, glatiramer and fingolimod (and other named agents where listed). Note: step therapy does not apply for primary progressive multiple sclerosis for J2350.

J2777/J2778 (Vabysmo, Lucentis): Trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar. For Vabysmo (J2777) additional trial and failure of aflibercept, ranibizumab or Beovu is also required.

J3245/J3247/J3590 (selected IL‑inhibitors/biologics): Trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana; MAPD members may also require trial and failure of adalimumab. Exceptions for specific indications are noted on the line entries.

Drug-specific prior auth and step therapy criteria

Coverage and prior authorization when the following drug-specific conditions are met:

Bimekizumab (Bimzelx) - J3590: Prior authorization and step therapy: trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana. Trial and failure of Steqeyma/Pyzchiva/Wezlana is NOT required for ankylosing spondylitis. MAPD members may also require trial and failure of adalimumab.

Bevacizumab (Avastin) biosimilar preference - J9035 etc.: Use preferred bevacizumab biosimilars Zirabev and Mvasi prior to other bevacizumab products; for retinal disorder indications prior authorization is not required.

Hyaluronic acid intra‑articular products (J7320–J7332): Prior authorization requires trial and failure of Durolane, Euflexxa, Gelsyn‑3 AND Supartz FX (these preferred products do not require authorization) before authorizing the listed IA hyaluronic acid products.

Docetaxel products (J9172/J9174): Step therapy: documented trial and failure of Taxotere is required prior to authorization for Docivyx and Beizray; Taxotere does not require authorization.

Covered with step therapy and preferred agent requirements

Coverage for listed biosimilars/agents is subject to meeting the following step therapy and preferred-agent conditions where specified:

Q5135 (Tocilizumab-aazg): Coverage requires trial and failure of Tyenne AND trial and failure of Inflectra or Avsola. For MAPD members, trial and failure of adalimumab and Tyenne SC is also required. Exceptions: Tyenne SC is not required for cytokine release syndrome and COVID‑19; infliximab and adalimumab are not required for cytokine release syndrome or giant cell arteritis.

Denosumab biosimilar entries (Q5136, Q5157, Q5158, Q5159, Q5161, Q5162): Coverage requires use/trial of preferred denosumab biosimilars such as Stoboclo or Osenvelt; preferred products in these groups may not require prior authorization. Specific preferred product and effective dates vary by code.

Q5146 (Trastuzumab Hercessi) and trastuzumab biosimilars: Coverage requires use of preferred trastuzumab biosimilars Ontruzant AND Trazimera where step therapy indicates; preferred trastuzumab biosimilars do not require prior authorization.

Aflibercept Q‑codes (Q5147, Q5149, Q5150, Q5153, Q5155): Coverage requires trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar prior to these aflibercept products.

Ustekinumab Q9997/Q9998/Q9999: Coverage requires trial and failure of preferred ustekinumab agents (Steqeyma, Pyzchiva, Wezlana); preferred drugs do not require authorization.

Preferred agents identified in the table (for example, Inflectra®, Avsola®, Steqeyma®, Pyzchiva®, Wezlana® and others) do not require prior authorization. Where a non-preferred agent lists a step therapy requirement, providers must document trial and therapeutic failure of the named preferred alternatives before the plan will authorize coverage. Notes attached to specific J- or Q-codes modify or waive step therapy for particular diagnoses or settings (for example, trial of Steqeyma/Pyzchiva/Wezlana is not required for rheumatoid arthritis for certain agents).

For Injectafer (J1439), prior authorization is not required when the infusion is administered through a dialysis facility. When Injectafer is provided in other settings, the J1439 line requires prior authorization and documentation of the required step‑therapy trials (trial and failure of at least two preferred iron products) before coverage will be approved.

The step therapy requirements for ocrelizumab entries do not apply when the diagnosis is primary progressive multiple sclerosis. For J2350/J2351, the table explicitly states that trial and failure of dimethyl fumarate, glatiramer and fingolimod is not required for primary progressive MS.

For agents such as secukinumab (J3247) and related entries, the policy notes an exception for ankylosing spondylitis: trial and failure of Steqeyma®, Pyzchiva® or Wezlana® is not required to meet step therapy for that diagnosis. Preferred-product trial requirements remain in place for other indications unless otherwise specified.

Bevacizumab (Avastin® / related J-codes) used for retinal disorders is exempt from prior authorization. The table indicates that prior authorization is not required for use in retinal disorders, and providers should follow the submission routing indicated for ophthalmic agents when applicable.

Tocilizumab biosimilar/variant entries (e.g., Q5135/Q5156) include standard step therapy requiring trial and failure of Tyenne and an infliximab biosimilar (Inflectra® or Avsola®) and, for MAPD members, adalimumab and Tyenne SC. Exceptions are explicitly listed: Tyenne SC is not required when used for cytokine release syndrome or COVID‑19. The policy also states that infliximab and adalimumab are not required for cytokine release syndrome or for giant cell arteritis in the tocilizumab entries.

HCPCS / J‑codes / Q‑codes and Related Coding Lists

What Providers Must Do / Submission and Documentation

Prior Authorization

Prior Authorization & Submission Requirements

Prior authorization is required for many medical-benefit drugs listed in this document. Providers must submit prior authorization requests through the channel specified for each drug: typically the Medical and Pharmacy Drug PA Portal for most medical benefit and CAR‑T therapies, and OncoHealth for many oncology and supportive care drugs. If a drug is being prescribed for a non‑oncology diagnosis but the table lists OncoHealth as the submission portal, do not submit to OncoHealth — instead call the Pharmacy Clinical Help Desk at 1‑800‑437‑3803. Failure to obtain required prior authorization before administration may result in denial of coverage.

Submit authorization requests via the Medical and Pharmacy Drug PA Portal for most listed J‑ and Q‑codes (e.g., CAR‑T codes Q2053–Q2056, many high‑cost biologics and IV therapies).
Submit oncology and supportive‑care drug PA requests to OncoHealth when indicated (several J‑codes such as J2506, J2820 and many others list OncoHealth as the required portal).
Do NOT route non‑oncology uses through OncoHealth even if the drug’s row indicates OncoHealth — call the Pharmacy Clinical Help Desk at 1‑800‑437‑3803 for those cases.
For certain drugs there are site‑of‑service exceptions (for example, Injectafer J1439 does not require prior authorization when administered through a dialysis facility).
Include required step‑therapy documentation when applicable (document trial and failure of specified preferred agents such as listed biosimilars or branded alternatives). Missing step‑therapy evidence may result in denial.
Follow the effective dates shown in the table — authorization requirements and portal routing may change on the effective dates listed in the revision history.
For CAR‑T therapies and other therapies explicitly listed to submit via the Medical and Pharmacy Drug PA Portal, route the authorization request through that portal (examples: Q2053 Tecartus, Q2054 Breyanzi, Q2055 Abecma, Q2056 Carvykti).
When a preferred biosimilar or preferred drug is required by step therapy (for example, preferred trastuzumab biosimilars Ontruzant and Trazimera, preferred pegfilgrastim and filgrastim biosimilars), document trial and failure of those agents per the drug row before requesting authorization for non‑preferred products.

Step Therapy

Documentation & Step Therapy

Many drugs in the list include step therapy requirements or other documentation that must be provided with the authorization request. Providers must ensure the PA request includes clinical records demonstrating trials and documented failures of the required preferred agents (or reasons why step therapy is not appropriate). Incomplete documentation or failure to meet step therapy will increase the risk of denial.

Step therapy examples: trial and failure of Inflectra or Avsola and designated preferred agents (Steqeyma, Pyzchiva, Wezlana) for several TNF/anti‑TNF biologics (e.g., abatacept J0129, certolizumab J0717, infliximab J1745 and many IV biologics).
Pegfilgrastim biosimilar step therapy: use preferred pegfilgrastim products (e.g., Fulphila AND Neulasta or Neulasta OnPro) where specified (e.g., Q5111, Q5120, Q5122, Q5127, Q5130).
Bevacizumab/ranibizumab/aflibercept ophthalmic step therapy: trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar is required before approving ranibizumab/aflibercept products (e.g., J0177/J0178, J2777/J2778, Q5124, Q5128).
Some cancer agents require trial/failure of specific chemotherapies (e.g., docetaxel products J9172/J9174 require trial and failure of Taxotere; gemcitabine products J9184 require trial and failure of generic gemcitabine).

Denial Risk

Denial Risk & Common Pitfalls

Where the table indicates a denial risk, providers should be aware that failure to obtain PA, to submit via the specified portal, or to include required step‑therapy and clinical documentation may result in claim denial and delay in patient care.

If the drug row lists the Medical and Pharmacy Drug PA Portal or OncoHealth, submit through that portal — requests routed elsewhere may be returned or denied.
For drugs added to the authorization list on a specific effective date, obtain authorization for administrations on or after that date as indicated (see effective‑date entries per code).
Examples of denial triggers: missing PA for newly added codes (e.g., J9350 Mosunetuzumab effective 4/1/2026), lack of step‑therapy evidence (e.g., required biosimilar trials), or incorrect portal submission.

Initial Therapy and Trial Requirements

Initial therapy/step requirements examples

Examples of initial therapy step requirements from the list

Orencia (J0129): Initial coverage requires trial and failure of Inflectra or Avsola AND trial and failure of Steqeyma, Pyzchiva or Wezlana. MAPD members also require trial and failure of adalimumab and Orencia SC per line entry. Preferred drugs do not require prior authorization.

Eylea (J0177/J0178): Initial therapy requires documented trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar prior to coverage.

Evkeeza/Leqvio (J1305/J1306): Initial therapy requires trial and failure of a high‑intensity statin AND Praluent or Repatha before authorization.

Iron product step therapy

Examples of step therapy for iron infusion products

Ferric derisomaltose and ferric carboxymaltose (J1437, J1439): Prior authorization/step therapy: trial and failure of at least TWO of the following preferred medications first: Ferrlecit, Feraheme, Venofer or INFeD. Preferred drugs do not require prior authorization. Note: Injectafer (J1439) is exempt from prior authorization when administered through a dialysis facility per line entry.trial and failure of >=2 preferred iron agents

Initial therapy requirements

Initial coverage requires documented trials of preferred agents where specified.

Ocular biologics (J2777/J2778): Initial coverage requires trial and failure of bevacizumab or a bevacizumab biosimilar; for Vabysmo (J2777) additional trial/failure of aflibercept, ranibizumab or Beovu is required.

Initial therapy - IA hyaluronic acids

Hyaluronic acid intra‑articular products

IA hyaluronic acids (J7320–J7322 and related codes): Initial step therapy: trial and failure of Durolane, Euflexxa, Gelsyn‑3 AND Supartz FX required before authorizing listed hyaluronic acid IA products. These preferred agents do not require prior authorization.

Initial step therapy examples

Examples of initial step therapy requirements

Q5135 (Tocilizumab biosimilar) initial requirement: Initial coverage requires trial and failure of Tyenne AND trial and failure of Inflectra or Avsola; for MAPD members also trial/failure of adalimumab and Tyenne SC except where clinical exceptions apply.

Step Therapy Tables and Drug‑Specific Triggers

Step therapy requirement	Drugs / Codes (examples)	Required prior trial(s) / failure(s)
Preferred biosimilar or alternative trial required	Abatacept (J0129 - Orencia)	Trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana; MAPD members also require trial/failure of adalimumab and Orencia SC (exceptions noted).
Bevacizumab biosimilar preference	Aflibercept / Eylea (J0177/J0178), Vabysmo (J2777), Ranibizumab biosimilars (Q5124, Q5128)	Trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar (preferred Zirabev and Mvasi where specified).
Preferred filgrastim/pegfilgrastim required	Filgrastim (J1442 / J1447), Pegfilgrastim biosimilars (Q5120, Q5122, Q5130, Q5130 etc.)	Use both preferred filgrastim biosimilars Nivestym AND Zarxio; for pegfilgrastim use Fulphila AND Neulasta or Neulasta OnPro prior to other agents.
Preferred infliximab / ustekinumab / denosumab steps	Infliximab entries (J1745, Q5104), Ustekinumab / other biologics (J3590, Q9997–Q9999), Denosumab (J0897, Q5136, Q5157–Q5162)	Trial and failure of Inflectra and Avsola for infliximab biosimilars; trial and failure of preferred ustekinumab products (Steqeyma, Pyzchiva, Wezlana) for ustekinumab biosimilars; use preferred denosumab biosimilars (Stoboclo or Osenvelt) per code-specific notes.
Document trials/failures of listed preferred agents	Multiple IV biologics and J3590/Q5135 entries (examples: J2327, J3245, J3590, Q5135)	Providers must document trial and clinical failure or intolerance to the specified preferred agents (Inflectra/Avsola, Steqeyma/Pyzchiva/Wezlana, Tyenne, etc.) prior to approval.
Sequential intravesical/systemic failure required	Anktiva (J9028), Adstiladrin (J9029), Inlexzo (J9183)	For BCG‑unresponsive NMIBC: must try and fail specified intravesical agent(s) (e.g., Adstiladrin) AND systemic checkpoint inhibitor (Keytruda or Keytruda Qlex) before coverage of Anktiva or Inlexzo where listed.
Taxotere (docetaxel) failure required	Docetaxel products (J9172 Docivyx, J9174 Beizray)	Trial and failure of Taxotere is required prior to coverage; Taxotere itself does not require authorization.
Generic / prior agent failure required before specialty formulations	Abraxane (J9264), Onivyde (J9205), generic pemetrexed vs brand (J9304/J9332 group)	Examples: Abraxane—trial and failure of generic paclitaxel; Onivyde—try and fail conventional irinotecan; some pemetrexed products—trial and failure of both Alimta and generic pemetrexed.
Preferred trastuzumab biosimilars required first	Trastuzumab products (J9355/J9356; Q5112–Q5116; Q5146 Hercessi)	Use preferred trastuzumab biosimilars Ontruzant AND Trazimera where step therapy indicates before other trastuzumab formulations.
Tocilizumab / Tyenne step therapy	Tocilizumab entries (Q5133, Q5135, Q5135 unbranded) and related J-codes	Trial and failure of Tyenne AND trial and failure of Inflectra or Avsola; MAPD members may also require trial/failure of adalimumab and Tyenne SC. Exceptions listed for cytokine release syndrome, COVID-19, and giant cell arteritis.
Efgartigimod / neuromuscular agents step	Vyvgart (J9332), Rystiggo (J9333), Vyvgart Hytrulo (J9334)	For myasthenia gravis: trial and failure of preferred rituximab biosimilars Truxima, Ruxience or Riabni required; for CIDP some entries require trial/failure of IVIG products such as Gammagard or Octagam.
Bevacizumab required prior to ranibizumab/aflibercept variants	Ranibizumab biosimilars (Q5124, Q5128, Q5128 Cimerli), Aflibercept biosimilars (Q5147, Q5149 etc.)	Trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar (Zirabev/Mvasi where specified) is required before ranibizumab or certain aflibercept products.
Step therapy criteria added/updated (revision history)	Multiple products (examples: Evenity, Entyvio, Vabysmo, Vyvgart, Herceptin Hylecta, Q5146, J3590 updates)	Document notes: step therapy criteria were added or modified for multiple agents with effective dates shown in revision entries; refer to specific code entries for updated required trials.

Step therapy — Preferred product(s)	Affected drug(s) / codes	Required trial & failure
Inflectra or Avsola AND Steqeyma/Pyzchiva/Wezlana (preferred)	Abatacept (J0129), Certolizumab (J0717), Risankizumab (J2327), Tildrakizumab (J3245), Mirikizumab (J2267), Golimumab (J1602)	Trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana; MAPD members may also require trial/failure of adalimumab per code notes.
Nivestym AND Zarxio (preferred filgrastim biosimilars)	Filgrastim (J1442), Tbo-filgrastim (J1447), Filgrastim biosimilars (Q5148, Q5125, Q5148 etc.)	Use both Nivestym and Zarxio prior to authorizing listed filgrastim products as specified in each entry.
Fulphila AND Neulasta (preferred pegfilgrastim)	Pegfilgrastim products (J2506, Q5120, Q5122, Q5130, Q5130 group)	Required to use Fulphila AND Neulasta or Neulasta OnPro before coverage of other pegfilgrastim biosimilars as listed (step therapy applies).
Zirabev AND Mvasi (preferred bevacizumab biosimilars)	Bevacizumab (J9035 / J9035, Q5107, Q5129, Q5129 etc.)	Use both Zirabev and Mvasi as preferred bevacizumab biosimilars prior to other bevacizumab products where indicated; retinal uses may be exempt from PA.
Truxima, Ruxience, Riabni (preferred rituximab biosimilars)	Rituximab products (J9311, J9312 and related entries)	Use all preferred rituximab biosimilars (Truxima, Riabni AND Ruxience) before authorizing certain rituximab formulations; preferred biosimilars don't require authorization.
Ontruzant AND Trazimera (preferred trastuzumab biosimilars)	Trastuzumab products (J9355/J9356; Q5112–Q5114; Q5146 Hercessi)	Use Ontruzant and Trazimera before other trastuzumab formulations when step therapy indicates; preferred biosimilars are noted as not requiring authorization.
Stoboclo or Osenvelt (preferred denosumab biosimilars)	Denosumab entries (J0897 Xgeva, J3590 Enoby/Xtrenbo; Q5136, Q5157–Q5162 etc.)	Use the preferred denosumab biosimilar Stoboclo (or Osenvelt where indicated); some preferred denosumab products do not require prior authorization and effective dates vary by code.
Tyenne (tocilizumab) and Inflectra/Avsola	Tocilizumab entries (Q5133 To fidence, Q5135 Tyenne, Q5135 unbranded biosimilar) and related J-codes	Trial and failure of Tyenne AND trial and failure of Inflectra or Avsola required; MAPD members may also require trial/failure of adalimumab and Tyenne SC except in designated exclusions (CRS, COVID-19, GCA).
Steqeyma, Pyzchiva, Wezlana (preferred ustekinumab/IL-12/23)	Ustekinumab and related biosimilars (J3590 entries, Q9997–Q9999)	Trial and failure of Steqeyma, Pyzchiva and Wezlana required for certain ustekinumab biosimilars; preferred drugs don't require authorization (see code-specific effective dates).
Truxima/Ruxience/Riabni prior to neuromuscular agents	Vyvgart (J9332), Rystiggo (J9333), Vyvgart Hytrulo (J9334)	For myasthenia gravis: trial and failure of Truxima, Ruxience or Riabni is required; for CIDP, trial and failure of Gammagard or Octagam is required for some entries.

J-/Q-code	Product	Step therapy condition (must be met prior to authorization)
J3590	Bimekizumab / multiple J3590 entries (Bimzelx, Enoby, etc.)	Trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana required where indicated; exceptions noted (e.g., ankylosing spondylitis).
J9028	Anktiva (Ogapendekin alfa)	For BCG‑unresponsive non‑muscle invasive bladder cancer: must try and fail both Adstiladrin AND Keytruda or Keytruda Qlex prior to Anktiva coverage.
J9172 / J9174	Docetaxel products (Docivyx, Beizray)	Trial and failure of Taxotere is required prior to authorization; Taxotere does not require authorization.
J9183	Gemcitabine intravesical system (Inlexzo)	For BCG‑unresponsive NMIBC: must try and fail both Adstiladrin AND Keytruda or Keytruda Qlex prior to coverage.
J9205	Irinotecan liposome (Onivyde)	For pancreatic cancer: must try and fail conventional irinotecan before Onivyde will be authorized.
J9264	Paclitaxel protein-bound particles (Abraxane)	For metastatic breast cancer and NSCLC: must first try and fail generic paclitaxel prior to Abraxane.
J9035 / Q5129 / Q5107	Bevacizumab / bevacizumab biosimilars (Avastin, Zirabev, Mvasi, Vegzelma)	Use preferred bevacizumab biosimilars Zirabev and Mvasi prior to other bevacizumab products where indicated; trial/failure of bevacizumab is required for some ocular agents and ranibizumab biosimilars.
Q5124 / Q5128 / Q5128	Ranibizumab biosimilars (Byooviz, Cimerli, etc.)	Trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar required prior to ranibizumab biosimilars.
Q5135 / Q5133 / Q5136	Tocilizumab products (Tyenne, Tofidence, denosumab group overlap)	Tocilizumab: trial and failure of Tyenne AND trial and failure of Inflectra or Avsola required; MAPD adalimumab/Tyenne SC requirements and listed exceptions apply.
Q5112–Q5116 / J9355–J9356	Trastuzumab products and biosimilars (Ontruzant, Trazimera, Herceptin, Herceptin Hylecta)	Use preferred trastuzumab biosimilars Ontruzant AND Trazimera where step therapy indicates before other trastuzumab products.
Q5120 / Q5122 / Q5130 / Q5130	Pegfilgrastim products (Ziextenzo, Nyvepria, Fylnetra, etc.)	Use Fulphila AND Neulasta or Neulasta OnPro prior to other pegfilgrastim biosimilars as listed per code.
J9311 / J9312	Rituximab / Rituxan Hycela and related rituximab products	Must use all preferred rituximab biosimilars (Truxima, Riabni AND Ruxience) before certain rituximab formulations; preferred biosimilars do not require authorization.
Q9997–Q9999 / J3590 updates	Ustekinumab biosimilars and related updated codes	Trial and failure of preferred ustekinumab drugs Steqeyma, Pyzchiva and Wezlana required for listed ustekinumab biosimilars per code entries; revision history notes added step therapy effective dates.

Coverage label	Drug / code	Documented prior therapy required
covered_with_criteria	Bimekizumab (J3590 - Bimzelx and other J3590 entries)	Document trial and failure of Inflectra or Avsola AND Steqeyma, Pyzchiva or Wezlana prior to approval; MAPD adalimumab requirement where specified; ankylosing spondylitis exception noted.
covered_with_criteria	Anktiva (J9028)	Documented failure of both Adstiladrin AND Keytruda or Keytruda Qlex required for BCG‑unresponsive NMIBC prior to approval.
covered_with_criteria	Docetaxel products (J9172 Docivyx, J9174 Beizray)	Documented failure of Taxotere required prior to approval; Taxotere does not require authorization.
covered_with_criteria	Gemcitabine intravesical system (J9183 Inlexzo)	Documented failure of Adstiladrin AND Keytruda or Keytruda Qlex for BCG‑unresponsive NMIBC required prior to approval.
covered_with_criteria	Bevacizumab / ranibizumab / aflibercept biosimilars (J9035, Q5124, Q5128, Q5147, Q5129)	Document trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar (Zirabev, Mvasi) prior to authorization for listed ocular or biosimilar products where specified.
covered_with_criteria	Tocilizumab products (Q5133, Q5135, Q5135 unbranded)	Document trial and failure of Tyenne AND Inflectra or Avsola; MAPD adalimumab/Tyenne SC requirements and exceptions are specified in code entries.
covered_with_criteria	Trastuzumab products (J9355/J9356, Q5112–Q5116, Q5146)	Documented trials of preferred trastuzumab biosimilars Ontruzant AND Trazimera required prior to authorization of other trastuzumab products where step therapy applies.
covered_with_criteria	Pegfilgrastim products (Q5120, Q5122, Q5130, Q5130 group)	Documented use and failure of Fulphila AND Neulasta or Neulasta OnPro required prior to approval of other pegfilgrastim biosimilars.
covered_with_criteria	Rituximab-related neuromuscular agents (J9332, J9333, J9334)	Documented trial and failure of preferred rituximab biosimilars (Truxima, Ruxience or Riabni) required for MG indications; CIDP indications require trial/failure of IVIG agents per code.
covered_with_criteria	Infliximab biosimilars / related (J1745, Q5104)	Document trial and failure of Inflectra AND Avsola prior to authorization of infliximab biosimilar entries as listed.

Step therapy condition	Product / code	Required documented failures
Sequential intravesical then systemic failure required	Anktiva (J9028), Adstiladrin (J9029), Inlexzo (J9183)	For BCG‑unresponsive non‑muscle invasive bladder cancer: must try and fail the intravesical agent (Adstiladrin) AND a systemic agent (Keytruda or Keytruda Qlex) prior to Anktiva or Inlexzo coverage.
BCG‑unresponsive NMIBC intravesical requirement	Gemcitabine intravesical system (J9183 Inlexzo)	Document failure of Adstiladrin AND Keytruda or Keytruda Qlex required for authorization in the indicated NMIBC setting.
Pan‑therapeutic sequencing for certain oncology agents	Irinotecan liposome (J9205), Onivyde; Paclitaxel protein‑bound (J9264) Abraxane	Onivyde: must try and fail conventional irinotecan; Abraxane: must try and fail generic paclitaxel before approval for listed indications.
Docetaxel family prior‑therapy requirement	Docetaxel (J9172 Docivyx, J9174 Beizray)	Trial and failure of Taxotere required; Taxotere does not require authorization.
Revision / effective‑date notes (affecting step sequencing)	Multiple codes and updates (see revision history)	Revision history documents added/changed step therapy requirements for several products (e.g., Anktiva, Q5135, J3590 updates) with effective dates—refer to specific code entries for required sequencing.

Coverage label	Drug / code	Prior trial documented (examples)
covered_with_criteria	Docetaxel products (J9172, J9174)	Documented failure of Taxotere required prior to approval (Taxotere does not require authorization).
covered_with_criteria	Abraxane (J9264)	Documented trial and failure of generic paclitaxel required prior to approval for metastatic breast cancer and NSCLC indications.
covered_with_criteria	Onivyde (J9205)	For pancreatic cancer, must document trial and failure of conventional irinotecan before Onivyde will be authorized.
covered_with_criteria	Gemcitabine intravesical system (J9183 Inlexzo)	Documented failure of Adstiladrin AND Keytruda or Keytruda Qlex required for BCG‑unresponsive NMIBC prior to approval.
covered_with_criteria	Anktiva (J9028)	Sequential documented failures required: Adstiladrin AND Keytruda or Keytruda Qlex prior to Anktiva coverage for the specified bladder cancer indication.

Coverage label	Drug / code	Prior trials/failures to document
covered_with_criteria	Docetaxel (J9172, J9174)	Document trial and failure of Taxotere prior to authorization.
covered_with_criteria	Gemcitabine (J9184) and Gemcitabine intravesical (J9183)	J9184: trial and failure of generic gemcitabine required; J9183/J9028: sequential failure of intravesical (Adstiladrin) and systemic (Keytruda/Keytruda Qlex) agents required where indicated.
covered_with_criteria	Abraxane (J9264) and Onivyde (J9205)	Abraxane: documented failure of generic paclitaxel required; Onivyde: documented failure of conventional irinotecan required prior to approval.
covered_with_criteria	Rituximab‑related products (J9311/J9312; J9332–J9334)	Document prior trials and failures of preferred rituximab biosimilars (Truxima, Ruxience, Riabni) before authorizing neuromuscular or related agents; CIDP indications require trial/failure of IVIG (Gammagard/Octagam) where specified.
covered_with_criteria	Infliximab / Infliximab biosimilars (J1745, Q5104)	Document trial and failure of Inflectra and Avsola prior to approval of infliximab biosimilar entries.

Coverage label	Trastuzumab biosimilar products	Step therapy requirement
covered_with_criteria	Ontruzant (Q5112), Trazimera (Q5116), Herzuma (Q5113), Ogivri (Q5114), Hercessi (Q5146), Herceptin (J9355)	Use preferred trastuzumab biosimilars Ontruzant AND Trazimera (both) before other trastuzumab products where step therapy applies; preferred biosimilars noted as not requiring authorization.
covered_with_criteria	Herceptin Hylecta (J9356) and other trastuzumab formulations (J9355, J9356, Q5112–Q5116)	Step therapy: trial and failure/use of both preferred trastuzumab biosimilars Ontruzant and Trazimera required prior to authorization of non-preferred trastuzumab products.

Coverage label	Pegfilgrastim-related codes	Step therapy requirement
covered_with_criteria	Pegfilgrastim (J2506), Pegfilgrastim biosimilars (Q5120, Q5122, Q5130, Q5130 group, Q5120 Ziextenzo, Q5130 Fylnetra)	Step therapy requires use of all the following preferred pegfilgrastim drugs: Fulphila AND Neulasta or Neulasta OnPro before other pegfilgrastim biosimilars will be authorized.
covered_with_criteria	Q5111 / Q5112 / Q5130 and related pegfilgrastim codes	Providers must document trials of preferred pegfilgrastim products as specified (Fulphila AND Neulasta/Neulasta OnPro) prior to approval of non-preferred pegfilgrastim agents.

Coverage label	Bevacizumab / ranibizumab / aflibercept entries	Step therapy requirement
covered_with_criteria	Bevacizumab (J9035 / Q5107 / Q5129 / Q5129 Vegzelma), Ranibizumab biosimilars (Q5124 Byooviz, Q5128 Cimerli), Aflibercept variants (Q5147 Pavblu, Q5149 Enzeevu)	Trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar required prior to authorization of ranibizumab and aflibercept products; preferred bevacizumab biosimilars Zirabev and Mvasi must be used where specified. Retinal uses of bevacizumab may be exempt from prior authorization per code notes.
covered_with_criteria	Ranibizumab (Q5124, Q5128) and related ocular agents (J2777 Vabysmo interactions)	Bevacizumab trial/failure required; for Vabysmo additional trial/failure of aflibercept, ranibizumab, or Beovu may be required per entry.

Coverage label	Tocilizumab / related IL‑6 entries	Required documented prior trials/failures
covered_with_criteria	Tocilizumab (Q5133 Tofidence, Q5135 Tyenne, Q5135 unbranded) and related J/Q entries	Trial and failure of Tyenne AND trial and failure of Inflectra or Avsola required; MAPD members may also require trial/failure of adalimumab and Tyenne SC. Exceptions apply for cytokine release syndrome and COVID-19 and for giant cell arteritis regarding infliximab/adalimumab.

Coverage label	Example products (selected)	Named preferred agents trialed & failed (must document)
covered_with_criteria	Orencia (J0129)	Inflectra or Avsola; Steqeyma, Pyzchiva or Wezlana; MAPD: adalimumab and Orencia SC where specified.
covered_with_criteria	Skyrizi IV (J2327), Ilumya (J3245), Simponi Aria (J1602)	Inflectra or Avsola AND Steqeyma/Pyzchiva/Wezlana; MAPD adalimumab requirement where noted.
covered_with_criteria	Infliximab / Renflexis (J1745 / Q5104)	Inflectra AND Avsola trial and failure required prior to authorization of related infliximab biosimilars.
covered_with_criteria	Tocilizumab (Q5135 / Q5133)	Tyenne AND Inflectra or Avsola; MAPD adalimumab/Tyenne SC requirements and exceptions apply per entry.
covered_with_criteria	Denosumab biosimilars (Q5136, Q5157–Q5162, J3590 Enoby/Xtrenbo)	Preferred denosumab biosimilars such as Stoboclo or Osenvelt must be used/tried; some preferred denosumab products do not require authorization—see code-specific notes and effective dates.

Change type	Affected product(s) / codes (examples)	Notes (effective date / revision)
Step therapy criteria added	Evenity, Entyvio, Vabysmo, Vyvgart, Vyvgart Hytrulo, Rystiggo, Herceptin Hylecta	Revision history shows additional step therapy criteria were added for these products with specified effective dates (see revision entries).
Authorization requirement added/changed	J3590 (multiple agents), Q5135 (Tocilizumab-aazg), Q5146 (Hercessi), Q5147 (Pavblu), Q5148 (Nypozi) and others	Revision notes list authorization requirements added or code updates with effective dates (e.g., 7/1/2025, 6/1/2025, 5/1/2025). Refer to revision history for exact effective dates per code.
Preferred agent updates	Trastuzumab preferred biosimilars, pegfilgrastim/filgrastim preferred lists, bevacizumab biosimilars	Updates made to highlight changes to preferred agents and submission routing (e.g., OncoHealth/Novologix changes) with effective dates noted in revision history.

Site‑of‑Care Notes and Exceptions

Note

Biosimilar and Preferred Product Guidance

Note

Policy Background

This document is an administrative reference that maps medical‑benefit HCPCS (J- and Q-) codes for specified drugs to the payer’s prior authorization and step therapy requirements for Medicare Plus Blue and BCN Advantage members. It lists which drugs require prior authorization, where authorization requests must be submitted (for example, the Medical and Pharmacy Drug PA Portal or OncoHealth), the preferred agents that must be tried first, and specific exceptions tied to diagnoses or settings.

Definitions

Prior authorization — definition and notes

DefinitionPrior authorization — approval needed from the plan before the plan will cover the drug.

Practical effectFor drugs listed in this document, providers must obtain plan approval before the plan will cover the medical‑benefit drug; failure to obtain PA may result in denial of coverage.

Where to submitAuthorization requests are submitted via the channel shown in the table (usually the Medical and Pharmacy Drug PA Portal; some oncology/supportive care drugs via OncoHealth).

Step therapy — definition

DefinitionStep therapy — member must first try another drug to treat a medical condition before the plan will cover the drug.

Clinical meaningA requirement that the member has tried and failed one or more specified preferred medications (often biosimilars or first‑line agents) before a non‑preferred drug will be authorized.

Provider actionDocument prior trials and failures of the specified preferred agents when submitting the prior authorization request through the indicated portal.

Step therapy — explanation

ExplanationStep therapy requires documented trial and failure of one or more specified preferred medications (for example, Inflectra or Avsola and other named biosimilars or agents) before coverage of the requested non‑preferred drug.

ExamplesTypical examples include infliximab biosimilars (Inflectra/Avsola), bevacizumab biosimilars (Zirabev/Mvasi), and other named preferred agents listed per J/Q‑code.

ConsequencesFailure to document required step therapy may lead to denial of authorization for the listed J/Q codes.

Retinal disorders exception (bevacizumab)

Retinal useFor bevacizumab (J9035), prior authorization is not required when used for retinal disorders.

Other settingsBevacizumab entries still list step therapy and preferred biosimilars for non‑retinal oncology or systemic indications where PA may apply.

DocumentationIf used for a non‑retinal diagnosis, follow standard PA and step therapy documentation requirements per code entry.

Ankylosing spondylitis exception

Ankylosing spondylitis exceptionFor bimekizumab (Bimzelx listed under J3590) and secukinumab (J3247), trial and failure of Steqeyma, Pyzchiva or Wezlana is NOT required for ankylosing spondylitis per the policy notes.

MAPD noteSome entries still require trial and failure of adalimumab for members with a MAPD prescription drug plan; check the specific J‑code line for MAPD requirements.

Preferred drugsPreferred biosimilars named in these entries do not require prior authorization when used as the step therapy agents.

Preferred drugs / preferred biosimilar — examples

Preferred product listExamples of preferred drugs/biosimilars identified in the document include Tyenne SC, Inflectra, Avsola, Stoboclo, Osenvelt, Ontruzant, and Trazimera.

Effect on PAPreferred drugs listed generally do not require prior authorization and must be trialed/failed before coverage of non‑preferred products where step therapy applies.

Code‑specific preferencePreferred status and PA requirements vary by J‑ or Q‑code entry; confirm the preferred product named on the specific line when preparing an authorization request.

Revision History and Effective Dates

2026-05-11effective_date_update

Prior authorization effective date updated for J1569 (Gammagard Liquid) to 2026-05-11 for Medicare Plus Blue and BCN Advantage.

2025-07-01authorization_change

Authorization requirements and code updates effective 2025-07-01 (examples: J7172 Hympavzi, Q2058 Auctazyl, Q5098 Imuldosa, Q5099 Steqeyma, Q5100 Yesintek; authorization requirements added for J3590 entries and selected Q-codes).

2024-11-01step_therapy_added

Step therapy criteria added for immune globulin products and updates to preferred agents effective 2024-11-01 (examples include added step therapy for select IG products).

2026-06-01document_revisionLatest

Document revision stamp updated (Revised June 2026) reflecting multiple prior authorization and step therapy updates across listed codes.

2025-05-01step_therapy_added

Added additional step therapy criteria effective 2025-05-01 for multiple agents including Evenity, Entyvio, Vabysmo, Vyvgart and Vyvgart Hytrulo.

2025-01-01step_therapy_and_code_updates

Step therapy criteria and code updates effective 2025-01-01: added several J3590 entries and related step therapy requirements; code corrections and additions for select products.

2024-11-01step_therapy_added

Added step therapy requirements for immune globulin products effective 2024-11-01; multiple preferred-agent highlights updated for 2025.

2025-07-01code_and_authorization_updates

Code updates and authorization changes effective 2025-07-01 (examples: J7172 Hympavzi, Q2058 Auctazyl, Q5098 Imuldosa, Q5099 Steqeyma, Q5100 Yesintek) and authorization requirements added for several J3590 and Q-codes.

2025-06-01authorization_effective

Authorization requirement effective 2025-06-01 added for select J3590/Q-codes (example listed: Qfitlia and other entries noted in revisions).

2025-04-01code_updates_and_authorizations

Code updates effective 2025-04-01 and subsequent authorization requirements added for Q5147, Q5149, Q5150, Q5151 and other codes effective 2025-05-01 and 2025-06-01.

2026-06-01document_revisionLatest

Document revision stamp updated (Revised June 2026) capturing step therapy updates and effective dates across listed agents.

2024-10-01code_update

Code update effective 2024-10-01: Q5135 Tyenne; additional authorization entries added in late 2024 and early 2025 (see revision history).

2026-06-01document_revisionLatest

Document revision stamp updated (Revised June 2026) reflecting cumulative code and step therapy changes including examples for Evenity, Entyvio, Vabysmo, Vyvgart and others.

OpenPayer

Related Billing Codes

Medical Drug and Step Therapy Prior Authorization List — Medicare Plus Blue & BCN Advantage

Coverage and Step Therapy Criteria

HCPCS / J‑codes / Q‑codes and Related Coding Lists

What Providers Must Do / Submission and Documentation

Initial Therapy and Trial Requirements

Step Therapy Tables and Drug‑Specific Triggers

Site‑of‑Care Notes and Exceptions

Biosimilar and Preferred Product Guidance

Policy Background

Definitions

Revision History and Effective Dates