Medical Drug and Step Therapy Prior Authorization List — Medical benefit drugs requiring prior authorization or step therapy
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List of medical benefit drugs for Medicare Plus Blue and BCN Advantage members that require prior authorization or have step therapy requirements; intended for providers submitting authorization requests.
Authorization requirement effective 6/1/2026: J0598 Cinryze.
Authorization requirement effective 7/1/2026: J3590 Otarmeni.
Authorization requirement removed effective 7/1/2025: J7601 Ohtuvayre.
Authorization requirement effective 7/1/2025: J3590 Imaavy, J3590 Zevaskyn, Q9999 Ustekinumab-aauz, Q5135 Tocilizumab-aazg.
Authorization requirement effective 8/1/2025: Q5153 Opuviz.
Authorization requirement effective 8/20/2025: J9382 Bizengri, J9289 Opdivo Qvantig, J9275 Uloxcyt, J1326 Vyloy, J9276 Ziihera.
Authorization requirement effective 9/3/2025: J9210 Gamifant.
Code updates effective 7/1/2025: J7172 Hympavzi, Q2058 Auctazyl, Q5098 Imuldosa, Q5099 Steqeyma, Q5100 Yesintek.
Authorization requirement effective 6/1/2025: J3590 Qfitlia.
Authorization requirement effective 7/1/2025: Q9998 Selarsdi.
Coverage Criteria and Drug-specific Conditions
Covered with criteria (examples)
Coverage is conditional based on prior authorization and, where indicated, fulfillment of step therapy requirements as listed per drug.
Supports step therapy logic as written in table.
Step therapy applies to specified HCPCS codes.
Specific exceptions noted in table.
Specifies preferred biosimilars and differing requirements by indication/trade name.
IV iron step therapy (J1437, J1439)
Examples of step therapy coverage logic from the list:
Preferred drugs do not require prior authorization; Injectafer prior auth not required when received through a dialysis facility.
G-CSF biosimilar / pegfilgrastim sequencing
Examples of filgrastim/pegfilgrastim biosimilar/agent sequencing:
Applies to entries J1442 and J1447.
Applies to J1449, Q5120, Q5122, Q5127, Q5130 and related entries.
Biologic and MS disease-modifying therapy step therapy
Example biologic sequencing requirements for certain infused biologics:
Preferred drugs do not require prior authorization in those entries.
See per-code exceptions for disease-specific rules.
Skyrizi IV (J2327) step therapy
Covered when step therapy requirements are met
Preferred drugs listed do not require prior authorization
Ocrevus (J2350) step therapy
Covered when step therapy requirements are met
Vabysmo and ranibizumab (J2777/J2778) step therapy
Covered when step therapy requirements are met
Asthma biologics (J2356, J2357, J2786)
Covered when specified prior biologic trials have failed
Evenity (J3111) step therapy for osteoporosis
Covered when step therapy requirements are met
For very high-risk osteoporosis: trial and failure of zoledronate only or a denosumab product only if zoledronate is contraindicated.
Biosimilar and preferred product steps (multiple entries)
Coverage contingent on use/trial of preferred biosimilars or preferred drugs
Preferred biosimilars may not require prior authorization for indicated uses.
Submit via Medical and Pharmacy Drug PA Portal; prior auth effective dates noted per plan.
Applies across multiple Q51xx/Q5136/Q5157 entries.
Example: Bimzelx/J3590 initial coverage conditions
Covered when specified step therapy and submission rules are followed for the item
Submit via Medical and Pharmacy Drug PA Portal; prior auth effective dates noted per plan.
HA (viscosupplementation) step therapy
Hyaluronic acid intra-articular products
Preferred drugs don't require authorization; submit via Medical and Pharmacy Drug PA Portal.
Bevacizumab preferences and exceptions
Bevacizumab (J9035) coverage nuance
Submit oncology uses via OncoHealth as indicated.
Specific drug-level conditions
Docetaxel (J9172, J9174) and Tyvaso (J7686)
Submit via OncoHealth for these docetaxel entries.
Submit via Medical and Pharmacy Drug PA Portal.
Coverage conditional on step therapy and prior agents
Coverage for listed drugs is subject to the specific step therapy rules and prior authorization effective dates shown per J-code.
chunk 73
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chunks 78,79,81,82
chunks 84,85
chunk 88
Trastuzumab biosimilar preference
Covered when ALL of the following are met
Pegfilgrastim/Filgrastim step therapy
Coverage conditioned on prior use of preferred products
Preferred agents may not require authorization
Applies to Q5125 and J1442/J1447 entries
Ranibizumab/bevacizumab policy
Tocilizumab/Tyenne requirements
Infliximab and adalimumab not required for cytokine release syndrome or giant cell arteritis; Tyenne SC not required for cytokine release syndrome/COVID-19.
Tocilizumab biosimilar (Q5135) step therapy
Coverage for certain biosimilars is contingent on prior trials of preferred agents as specified below.
From chunk 108
Denosumab biosimilars step therapy
Coverage for denosumab biosimilars requires use of preferred denosumab biosimilars or trial/failure per entry.
From chunks 108,116,118,119
Aflibercept step therapy
Aflibercept biosimilars and related agents have step therapy requiring prior trial/failure of bevacizumab or its biosimilars.
From chunks 110,111,114
Trastuzumab biosimilar requirement
Trastuzumab biosimilars preference
From chunk 110
Ustekinumab IV step therapy
Ustekinumab IV biosimilars require trial and failure of preferred ustekinumab products.
From chunks 120-121
Preferred products named in the table are identified as not requiring prior authorization and are the required first-line agents for many step therapy rules. Where a step requirement exists, providers must document trial and failure of the specified preferred drug(s) (for example, trials of Inflectra® or Avsola® and Steqeyma®, Pyzchiva® or Wezlana® for certain IV biologics). Use of the preferred product as listed generally means no PA is required; requests for non-preferred or innovator products will require prior authorization and documentation that the preferred option(s) were tried and were ineffective or not tolerated.
For Injectafer® (J1439), step therapy requires trial and failure of at least two of the preferred IV iron products: Ferrlecit®, Feraheme®, Venofer® or INFeD®. Exception: prior authorization is not required when Injectafer® is administered through a dialysis facility.
For Simponi Aria® (J1602) and other listed IV biologics that require trials of preferred infliximab biosimilars and ustekinumab alternatives, the table specifically notes that trial and failure of Steqeyma®, Pyzchiva® or Wezlana® is NOT required for rheumatoid arthritis or ankylosing spondylitis.
Step therapy for Ocrevus® (J2350/J2351) requires trial and failure of listed disease‑modifying therapies (example: dimethyl fumarate, glatiramer and fingolimod) before approval; step therapy does not apply when Ocrevus is used for primary progressive multiple sclerosis.
Bevacizumab (Avastin®, J9035) has a preferred‑biosimilar sequencing requirement (use both Zirabev® and Mvasi® where specified). Separately, the document states that prior authorization is not required when Avastin is used for retinal disorders.
The excerpt does not list broad categorical exclusions; rather, coverage limitations are expressed as drug‑specific step therapy requirements or required prior agents. Where clinical or indication exceptions exist, they are noted per line item (for example, disease‑specific exceptions for step therapy).
The policy notes that Tyenne SC (tocilizumab subcutaneous) is not required as a step prior therapy for specific indications: Tyenne SC is not required for treatment of cytokine release syndrome and COVID‑19. When Tyenne SC is not required, associated step requirements that reference the subcutaneous formulation do not apply for those indications.
For tocilizumab and certain related entries the list clarifies that infliximab and adalimumab are not required as part of step therapy for some indications. Specifically, infliximab and adalimumab are not required for cytokine release syndrome or giant cell arteritis, so prior trials of those agents are not mandated for those diagnoses.
HCPCS / Q-code / J-code Listings and Dates
| J0178 | Aflibercept (Eylea) |
| J0179 | Brolucizumab-dbll (Beovu) |
| J0180 | Agalsidase beta (Fabrazyme) |
| J0185 | Aprepitant (Cinvanti) |
| J0217 | Velmanase alfa (Lamzede) |
| J0218 | Olipudase alfa-rpcp (Xenpozyme) |
| J0219 | Avalglucosidase alfa-ngpt (Nexviazyme) |
| J0221 | Alglucosidase alfa (Lumizyme) |
| J0222 | Patisiran (Onpattro) |
| J0223 | Givosiran (Givlaari) |
| J1325 | Epoprostenol (Flolan®, Veletri®) |
| J1326 | Zolbetuximab-clzb (Vyloy®) |
| J1411 | Etranacogene dezaparvovec-drlb (Hemgenix®) |
| J1413 | Delandistrogene moxeparvovec-rokl (Elevidys) |
| J1427 | Viltolarsen (Viltepso®) |
| J1428 | Eteplirsen (Exondys 51®) |
| J1429 | Golodirsen (Vyondys 53®) |
| J1434 | Fosaprepitant (Focinvez™) |
| J1437 | Ferric derisomaltose (Monoferric®) |
| J1439 | Ferric carboxymaltose (Injectafer®) |
| J2323 | Spinraza (nusinersen) reference appears in list |
| J2326 | Spinraza (nusinersen) listed |
| J2327 | Skyrizi IV (risankizumab-rzaa) |
| J2329 | Briumvi (ublituximab-xiiy) |
| J2350 | Ocrevus (ocrelizumab) |
| J2351 | Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) |
| J2356 | Tezspire (tezepelumab-ekko) |
| J2357 | Xolair (omalizumab) |
| J2506 | Neulasta (pegfilgrastim) |
| J2507 | Krystexxa (pegloticase) |
| J3590 | multiple generics/trade names listed under miscellaneous J3590 entries (e.g., Bimzelx/Bimekizumab-bkzx; Exdensur/Depemokimab-ulaa; Enoby/Denosumab-qbde; Xtrenbo/Denosumab-qbde; others) |
| C9399 | Omisirge / Omidubicel-onlv |
| J7170 | Emicizumab-kxwh (Hemlibra) |
| J7171 | ADAMTS13, recombinant-krhn (Adzynma) |
| J7172 | Marstacimab-hncq (Hympavzi) |
| J7320 | Sodium hyaluronate (GenVisc 850) |
| J7321 | Sodium hyaluronate (Visco-3 / Hyalgan) |
| J7322 | High Molecular Weight Viscoelastic Hyaluronan (Hymovis) |
| J7324 | High Molecular Weight Hyaluronan (Orthovisc) |
| J7325 | Hylan G-F 20 (Synvisc, Synvisc-One) |
| J9172 | Docetaxel (Docivyx) |
| J9173 | Durvalumab (Imfinzi) |
| J9174 | Docetaxel (Beizray) |
| J9176 | Elotuzumab (Empliciti) |
| J9177 | Enfortumab vedotin-ejfv (Padcev) |
| J9183 | Gemcitabine intravesical system (Inlexzo) |
| J9184 | Gemcitabine (Avgemsi) |
| J9204 | Mogamulizumab-kpkc (Poteligeo) |
| J9205 | Irinotecan liposome (Onivyde) |
| J9210 | Emapalumab-lzsg (Gamifant) |
| J9350 | Lunsumio (Mosunetuzumab-axgb) |
| Q2041 | Axicabtagene ciloleucel (Yescarta) CAR-T |
| Q2042 | Tisagenlecleucel (Kymriah) CAR-T |
| Q2053 | Brexucabtagene autoleucel (Tecartus) CAR-T |
| Q2054 | Lisocabtagene maraleucel (Breyanzi) CAR-T |
| Q2055 | Idecabtagene vicleucel (Abecma) CAR-T |
| Q2056 | Ciltacabtagene autoleucel (Carvykti) CAR-T |
| Q2057 | Afamitresgene autoleucel (Tecelra) |
| Q2058 | Obecabtagene autoleucel (Aucatzyl) |
| Q5098 | Ustekinumab-srlf (Imuldosa IV) |
| Q5100 | Ustekinumab-kfce (Yesintek IV) |
| Q4074 | Iloprost (Ventavis) |
| Q5101 | Filgrastim-sndz (Zarxio) |
| Q5104 | Infliximab-abda (Renflexis / unbranded biosimilar) |
| Q5107 | Bevacizumab-awwb (Mvasi) |
| Q5108 | Pegfilgrastim-jmdb (Fulphila) |
| Q5110 | Filgrastim-aafi (Nivestym) |
| Q5111 | Pegfilgrastim-cbqv (Udenyca) |
| Q5112 | Trastuzumab-dttb (Ontruzant) |
| Q5135 | Tocilizumab-aazg (Unbranded biosimilar) |
| Q5136 | Denosumab-bbdz / Jubbonti / Unbranded biosimilar / Wyost |
| Q5146 | Trastuzumab-strf (Hercessi) |
| Q5147 | Aflibercept-ayyh (Pavblu) |
| Q5148 | Filgrastim-txid (Nypozi) |
| Q5151 | Eculizumab-aagh (Epysqli) |
| Q5152 | Eculizumab-aeeb (Bkemv) |
| Q5153 | Aflibercept-yszy (Opuviz / Unbranded biosimilar) |
| Q5154 | Omalizumab-igec (Omlyclo / Unbranded biosimilar) |
| Q5155 | Aflibercept-jbvf (Yesafili) |
| J7601 | Ohtuvayre |
| J7172 | Hympavzi |
| Q2058 | Auctazyl |
| Q5098 | Imuldosa |
| Q5099 | Steqeyma |
| Q5100 | Yesintek |
| J3590 | multiple branded drugs listed under J3590 (e.g., Imaavy, Zevaskyn, Qfitlia, others) |
| Q9999 | Ustekinumab-aauz (and other Q9999 entries in document) |
| Q5135 | Tocilizumab-aazg |
| Q5153 | Opuviz |
| multiple | Numerous HCPCS/CPT codes throughout the revision history (examples include J0870, J9038, J1748, J3490, J3590, J9329, Q5115, J1628, J1299, J3392, J2802, J0870, J1307, J1414, J1552, J3393, J3394, J7171, J9361, etc.) |
What Providers Must Do / Authorization and Step Therapy Instructions
Obtain prior authorization for listed drugs
Prior authorization is required for the medical-benefit drugs listed in this document; the table includes per-code effective dates and submission routing (Medical and Pharmacy Drug PA Portal or OncoHealth) that providers must follow when requesting authorization.
Prior authorization required per J‑code entry
Follow the per-line entry requirement: each J-code shown in the table has a prior authorization requirement and effective date; submit authorization requests using the portal indicated for that J-code.
Confirm code-level PA and document step therapy per J‑code
For each J-code with a step or prior-authorization column, document the required step-therapy trials and request prior authorization using the submission channel noted for that specific J-code.
Use OncoHealth for oncology J‑code authorizations when indicated
Submit prior authorization requests for oncology J-codes through OncoHealth when the line item indicates OncoHealth; otherwise use the Medical and Pharmacy Drug PA Portal as shown.
Submit PA requests via PA Portal or OncoHealth as indicated
Many J-codes listed require prior authorization and show the Medical and Pharmacy Drug PA Portal (✓) as the primary submission route; follow the portal indicated on each line.
Follow PA requirements per HCPCS entry
The table shows per-HCPCS prior authorization requirements and effective dates; providers must request authorization using the portal identified for each HCPCS entry (Medical & Pharmacy Drug PA Portal or OncoHealth).
Prior authorization required for listed Q‑codes
Q-code entries in the list require prior authorization when shown; follow the per-product step therapy rules and submit requests via the Medical and Pharmacy Drug PA Portal or OncoHealth as indicated.
Document step therapy trials and failures
Providers must document required step-therapy trials (trial and failure of specified preferred alternatives) before prior authorization will be approved for many listed drugs.
- Document dates, agents tried, and reason for failure/intolerance in the PA request.
Step therapy requirements present (general)
Step therapy rules are present for multiple drugs; follow the per-drug required trials (examples below) before submitting a PA request.
Follow per-drug step therapy listed in table
For specific drugs, the table lists the exact step-therapy agents that must be tried and failed; providers must document those trials in the authorization request.
Comply with J‑code step therapy lists
Many J‑codes include step therapy specifying which preferred agents must be tried and failed (e.g., trials of Inflectra/Avsola and Steqeyma/Pyzchiva/Wezlana for several IV biologics); include that documentation in the PA submission.
Document trial and failure evidence for step therapy
Providers must document required trials and failures specified per J‑code; failure to provide this documentation may prevent approval.
Provide clinical rationale and prior-treatment history
Summaries in the table show required step-therapy trials for many agents; ensure the PA request identifies the prior agents tried and clinical rationale for failure or intolerance.
Step therapy requirements (per J‑code) — examples
The table includes examples and summaries of step therapy obligations — providers must follow the step rules shown per product (e.g., docetaxel, intravesical gemcitabine, pegfilgrastim sequencing) and submit supporting documentation.
Document step therapy trials or risk denial
Providers must document trials and failures of specified agents (step therapy trials) before prior authorization will be approved for many entries; missing documentation risks denial.
Submit PA requests through the portal shown per line item
For most entries the Medical and Pharmacy Drug PA Portal is the designated submission channel; oncology/supportive-care J-codes list OncoHealth where indicated. Submit via the portal marked on the line item.
- If OncoHealth is indicated but the diagnosis is non‑oncology, do not send to OncoHealth — call the Pharmacy Clinical Help Desk (per provider guidance).
Use the indicated portal (PA Portal vs OncoHealth)
When a line item shows a ✓ for the PA Portal, submit the prior authorization through the Medical and Pharmacy Drug PA Portal; when OncoHealth is indicated submit there for oncology/supportive-care items.
Primary submission channel = Medical & Pharmacy Drug PA Portal unless OncoHealth is marked
Most J‑codes are routed to the Medical and Pharmacy Drug PA Portal; select oncology and certain J‑codes require OncoHealth — check each line and submit via the channel marked.
Include step therapy details and effective dates when submitting
Authorization requests should be submitted through the Medical and Pharmacy Drug PA Portal for the majority of J-codes; oncology/supportive-care J-codes list OncoHealth. Include step-therapy and effective-date details in submissions.
OncoHealth submission required for indicated oncology entries
Some entries show OncoHealth (✓) as the submission portal — when OncoHealth is indicated send the authorization request there and include the documented step-therapy trials required for that drug.
Risk of noncoverage without prior authorization
Failure to obtain required prior authorization for listed drugs will result in lack of plan coverage; obtain authorization before providing the drug to avoid claim denial.
Dialysis facility exception for Injectafer (J1439)
Injectafer (J1439) has a dialysis‑facility exception: prior authorization is not required when administered through a dialysis facility; otherwise the step therapy and PA rules apply as listed.
Adhere to step therapy or risk PA denial
Step therapy adherence is required for many entries; if the member hasn't tried and failed the specified preferred agents, prior authorization may be denied.
Use and document preferred biosimilars where required
For products where preferred biosimilars are named (e.g., bevacizumab biosimilars), providers must document use of the preferred biosimilars as required; not using preferred biosimilars may affect authorization.
J9183 requires prior trials of Adstiladrin and Keytruda
J9183 (gemcitabine intravesical system) requires documented failure of both Adstiladrin and Keytruda (or Keytruda Qlex) for BCG‑unresponsive non‑muscle invasive bladder cancer; failure to document these prior therapies may cause denial.
Immunotherapy entries require specified prior agent (Loqtorzi) where indicated
Some immuno‑oncology agents used for nasopharyngeal cancer (e.g., pembrolizumab/nivolumab entries) require prior trial and failure of Loqtorzi; lack of documentation of that prior therapy may result in denial.
Document trials of preferred biosimilars (rituximab/efgartigimod) before non‑preferred
Preferred biosimilar sequencing is required for certain entries (e.g., efgartigimod/Vyvgart and rituximab hyaluronidase entries); providers must document trials/failures of the listed preferred biosimilars to avoid denial.
Obtain PA for newly added codes by effective date
Newly added codes listed in the revision history have effective authorization dates — providers must obtain prior authorization for these codes on or after the stated effective dates to avoid claim denials.
Initial Therapy / Start-of-Care Criteria
Initial therapy examples
Examples of initial step therapy rules from the list:
From J0129 entry.
From J0490 entry.
Initial therapy step rules (examples)
Initial coverage requires trial/failure of preferred agents where specified.
Submit via Medical and Pharmacy Drug PA Portal; effective date noted per entry.
Preferred drugs don't require authorization.
Initial therapy preferences
Failure of preferred agents required before non-preferred product authorization.
Initial therapy requirements
From chunks 108 and 110
Continuation / Renewal Criteria
Continuation
From chunk 93
Continuation therapy notes
From chunk 120
Step Therapy Table and Requirements
| General rule | Provider must document |
|---|---|
| Member must trial and fail specified preferred agents listed for the HCPCS/J-code before the plan will authorize the requested non-preferred drug. | Documentation of prior trials, dates, and reason for failure or intolerance must be included with the prior authorization request. |
| Preferred products named in the table typically do not require prior authorization and must be used first as step therapy when specified. | If preferred biosimilars or agents were used, include product name, administration dates, and clinical response to substantiate trial/failure. |
| Step therapy is a required condition of coverage for many listed J-/Q-/C-codes; requirements are shown per HCPCS entry in the table. | Provider must submit supporting medical records demonstrating failure, intolerance, or contraindication to required prior therapies. |
| HCPCS | Step therapy requirement |
|---|---|
| J1437 (Ferric derisomaltose, Monoferric) | Trial and failure of at least TWO of: Ferrlecit®, Feraheme®, Venofer® or INFeD® before approval. |
| J1439 (Ferric carboxymaltose, Injectafer) | Trial and failure of at least TWO of: Ferrlecit®, Feraheme®, Venofer® or INFeD®; prior authorization not required when administered through a dialysis facility. |
| HCPCS | Step therapy requirement |
|---|---|
| J1442 (Filgrastim, Neupogen) | Use both preferred filgrastim biosimilars Nivestym® AND Zarxio® prior to authorizing the listed filgrastim product. |
| J1447 (Tbo-filgrastim, Granix) | Use both preferred filgrastim biosimilars Nivestym® AND Zarxio® prior to authorization. |
| HCPCS | Step therapy requirement |
|---|---|
| J1449 (Eflapegrastim, Rolvedon) | Use all of the following preferred pegfilgrastim drugs before approval: Fulphila® AND Neulasta® or Neulasta OnPro. |
| HCPCS (examples) | Step therapy requirement |
|---|---|
| J1602 (Golimumab, Simponi Aria) / J1628 (Guselkumab, Tremfya IV) / J2267 (Mirikizumab IV) / J2327 (Risankizumab IV, Skyrizi IV) | Trial and failure of Inflectra® AND Avsola® AND one of Steqeyma®, Pyzchiva® or Wezlana® is required before these IV biologics; preferred drugs do not require prior authorization (additional MAPD adalimumab requirement may apply). |
| J1745 (Infliximab / generic) / J1745 (Infliximab biosimilars Q5104) | Trial and failure of Inflectra® AND Avsola® required prior to authorization of infliximab products; preferred biosimilars do not require authorization. |
| HCPCS | Step therapy requirement / exception |
|---|---|
| J2327 (Skyrizi IV) | Trial and failure of Inflectra® or Avsola® AND Steqeyma®, Pyzchiva® or Wezlana®; MAPD members may also require trial/failure of adalimumab. Preferred drugs do not require prior authorization. |
| HCPCS / Q-code | Documentation required |
|---|---|
| (See individual J/Q entries) | Providers must document trials and failures of the named preferred drugs specified per HCPCS/Q-code (product name, dates, clinical response, and reason for discontinuation) when step therapy is required. |
| When step therapy applies | Evidence required |
|---|---|
| Step therapy is required for many products listed (providers must trial preferred alternatives first as shown per HCPCS/Q-code). | Attach records showing prior product trials, dosing, dates, and clinical rationale for failure or intolerance; include MAPD-specific requirements when noted. |
| HCPCS | Step therapy requirement |
|---|---|
| J9172 / J9174 (Docetaxel products) | Trial and failure of Taxotere® is required prior to authorization of listed docetaxel products; Taxotere does not require authorization. |
| HCPCS | Step therapy requirement |
|---|---|
| J9183 (Gemcitabine intravesical system, Inlexzo) | For BCG-unresponsive non‑muscle invasive bladder cancer, must try and fail both Adstiladrin® AND Keytruda® or Keytruda Qlex™ before authorization. |
| HCPCS | Step therapy requirement |
|---|---|
| J9264 (Paclitaxel protein-bound, Abraxane) | For metastatic breast cancer and non‑small cell lung cancer, must first try and fail generic paclitaxel prior to authorization. |
| HCPCS | Step therapy requirement |
|---|---|
| J9205 (Irinotecan liposome, Onivyde) | For pancreatic cancer, must first try and fail conventional irinotecan prior to approval. |
| HCPCS | Step therapy requirement (nasopharyngeal cancer) |
|---|---|
| J9271 / J9277 (Pembrolizumab / Keytruda / Keytruda Qlex) and J9299 / J9289 (Nivolumab entries) | For use in nasopharyngeal cancer, must first try and fail Loqtorzi (toripalimab) where specified before authorization. |
| HCPCS examples | Biosimilar-first requirement |
|---|---|
| J9256 (Imaavy) / J9311, J9312 (Rituximab Hycela / Rituxan) / J9332–J9334 (Efgartigimod / Vyvgart entries) | Trial and failure of listed preferred biosimilars (e.g., Truxima, Ruxience, Riabni) is required before approving the referenced product; preferred biosimilars do not require authorization. |
| HCPCS / Q-code | Specific trial/failure requirements |
|---|---|
| J9355 / J9356 (Trastuzumab / Herceptin / Herceptin Hylecta) and Q5146 (Trastuzumab-strf) | Use both preferred trastuzumab biosimilars Ontruzant® AND Trazimera® prior to authorizing trastuzumab products; preferred biosimilars may not require prior authorization. |
| Q5124 / Q5128 (Ranibizumab Byooviz / Cimerli) | Trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar required before authorization. |
| Q/HCPCS | Tocilizumab-related step therapy |
|---|---|
| Q5133 / Q5135 (Tofidence / Tyenne / tocilizumab entries) | Trial and failure of Tyenne (tocilizumab) AND trial and failure of Inflectra® or Avsola® required for certain tocilizumab entries; MAPD members may also require trial/failure of adalimumab and Tyenne SC. Tyenne SC and infliximab/adalimumab are not required for cytokine release syndrome or COVID‑19 as noted. |
| Update summary | Notes |
|---|---|
| Step therapy additions/updates | The document notes additions and updates to step therapy requirements for multiple agents (examples: added step therapy for Keytruda and Opdivo in nasopharyngeal cancer; multiple J3590 and Q-code updates effective on listed dates). Providers should review effective dates per HCPCS/Q-code. |
Site of Care and Submission Routing
Submission routing: PA Portal (general) vs OncoHealth (oncology)
Use the Medical and Pharmacy Drug PA Portal for most submissions; oncology/supportive care submissions are routed to OncoHealth per the table — follow the portal indicated for each drug.
Dialysis‑facility exception for Injectafer
Injectafer (J1439) prior authorization is not required when administered through a dialysis facility; verify site of care when submitting.
Administration settings — infusion center/office/hospital outpatient
Most therapies are administered in infusion centers, physician offices, or hospital outpatient settings; submit authorizations via the Medical and Pharmacy Drug PA Portal or OncoHealth as specified per line item.
OncoHealth vs PA Portal indicated per product (site implication)
Some entries indicate OncoHealth as the submission portal (suggesting oncology/infusion center administration) while others use the Medical and Pharmacy Drug PA Portal; follow the table per product.
Biosimilar Preferences and Required Trials
Aflibercept requires prior trial/failure of bevacizumab
Bevacizumab/aflibercept sequencing: aflibercept products require trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar prior to approval.
Denosumab — use preferred biosimilars (Stoboclo/Osenvelt) where specified
Denosumab entries (Prolia/Xgeva and biosimilars) specify preferred denosumab biosimilars (Stoboclo for Prolia; Osenvelt for Xgeva); preferred products may not require prior authorization.
Filgrastim/pegfilgrastim preferred biosimilar sequencing required
Filgrastim/pegfilgrastim sequencing: providers must use preferred filgrastim biosimilars Nivestym AND Zarxio before authorizing listed filgrastim products (J1442/J1447); preferred pegfilgrastim sequencing is required for several Q‑codes.
IV biologics: trial/failure of Inflectra, Avsola and listed ustekinumab products
Several IV biologics require trial and failure of Inflectra AND Avsola and one of Steqeyma/Pyzchiva/Wezlana before the listed agents; adalimumab may also be required for MAPD members.
Denosumab preferred biosimilar Stoboclo specified
Denosumab preferred biosimilar Stoboclo is specified for certain denosumab product entries — when the preferred product is used prior authorization may not be required.
Denosumab preferred biosimilar Osenvelt specified
Denosumab preferred biosimilar Osenvelt is identified for specified denosumab entries; the preferred product may not require prior authorization.
Preferred bevacizumab biosimilars may not require PA for indicated uses
Preferred bevacizumab biosimilars (Zirabev, Mvasi) do not require prior authorization for indicated uses; use them before non-preferred bevacizumab products.
Denosumab entries — preferred biosimilars reduce PA need
Denosumab is listed with multiple trade names; when a preferred denosumab biosimilar is used (Stoboclo or Osenvelt) prior authorization may not be required.
Rituximab biosimilar sequencing required
Preferred rituximab biosimilars (Truxima, Ruxience, Riabni) must be used prior to brand rituximab products; the preferred biosimilars do not require authorization.
Ontruzant & Trazimera preferred for trastuzumab
Preferred trastuzumab biosimilars Ontruzant and Trazimera are identified as the required step agents for trastuzumab products (Ontruzant and Trazimera should be used before other trastuzumab products).
Pegfilgrastim preferred‑agent sequencing required
Pegfilgrastim biologics have preferred sequencing (Fulphila AND Neulasta or Neulasta OnPro) required before certain pegfilgrastim biosimilars; providers must document prior use of these preferred agents.
Zirabev and Mvasi preference for bevacizumab Q‑codes
Bevacizumab preferred biosimilars Zirabev and Mvasi are required to be used before other bevacizumab biosimilars in select Q-code entries.
Q5136 denosumab entry — Stoboclo preferred
Q5136 (Denosumab/Jubbonti) requires the preferred denosumab biosimilar Stoboclo where indicated.
Stoboclo or Osenvelt preferred for denosumab biosimilars
Preferred denosumab biosimilars Stoboclo or Osenvelt are specified across multiple Q-code entries; using the preferred product may obviate prior authorization.
Ontruzant and Trazimera required first for trastuzumab
Ontruzant and Trazimera are the preferred trastuzumab biosimilars required to be tried prior to non-preferred trastuzumab formulations; preferred agents typically do not require prior authorization.
Background and Scope
This document is an administrative prior authorization and step therapy list for Medicare Plus Blue and BCN Advantage members covering medical‑benefit drugs. It indicates which HCPCS/Q‑codes require prior authorization, identifies step therapy or preferred‑biosimilar sequencing rules, and shows the submission channel (primarily the Medical and Pharmacy Drug PA Portal or OncoHealth where indicated). The list is intended for providers and includes effective dates and site‑of‑care notes (for example, dialysis facility exceptions).
Definitions
Revision History and Policy Changes
Authorization requirement removed for J7601 (Ohtuvayre) effective 7/1/2025.
Document revised June 2026; includes multiple prior authorization and step therapy updates across listed HCPCS/Q-codes.
Authorization requirements added effective 7/1/2025 for J3590 Imaavy, J3590 Zevaskyn, Q9999 Ustekinumab-aauz, and Q5135 Tocilizumab-aazg.
Authorization requirement added effective 8/1/2025 for Q5153 Opuviz.
Authorization requirements added effective 8/20/2025 for J9382 Bizengri; J9289 Opdivo Qvantig; J9275 Uloxcyt; J1326 Vyloy; and J9276 Ziihera.
Authorization requirement added effective 9/3/2025 for J9210 Gamifant.
Authorization requirement effective 6/1/2025 added for J3590 Qfitlia.
Authorization requirement effective 7/1/2025 added for Q9998 Selarsdi.
Authorization requirement effective 6/1/2025 added for J0598 Cinryze (listed in revision history).
Authorization requirements effective 5/1/2025 and 6/1/2025 added for multiple Q-codes and J3590 entries (examples: Q5147 Pavblu, Q5149 Enzeevu, Q5150 Ahzantive, Q5151 Epysqli, Q5146 Hercessi, Q5148 Nypozi, J3590 Stoboclo, J3590 Encelto).
Authorization requirement effective 1/6/2025 added for certain J3590 entries including Hympavzi and Imuldosa IV noted in earlier revisions.
Step therapy updates noted in revision history
Step therapy updates are documented in the revision history; recent changes include additions of step therapy for Keytruda and Opdivo for nasopharyngeal cancer and other adjustments — review the revision notes for effective dates.
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