Modifiedblue cross blue shield - michiganPolicy N/A

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

A listing of medical-benefit drugs that require prior authorization or have step therapy requirements for Medicare Plus Blue and BCN Advantage members; intended for providers submitting PA 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 TypeAuthorization and step therapy updates

Effective DateRevised January 21, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests through the Medical and Pharmacy Drug PA Portal or OncoHealth as indicated for each drug.

SourceLink

POLICY UPDATE CHANGES

Authorization requirement effective 1/22/2026: J3358 Stelara

Authorization requirement effective 2/2/2026: J3590 Exdensur, J3590 Yartemlea

Updates made to step therapy requirements for Orencia, Cosentyx, Tofidence, Tyenne and the unbranded tocilizumab-aazg biosimilar effective 2/2/2026

Authorization requirement removed effective 1/1/2026: Q5115 Truxima, Q5103 Inflectra

Authorization requirement changed from Novologix to OncoHealth effective 6/1/2025 for codes including J0870 Rytelo and J9038 Niktimvo.

Added step therapy requirements for Keytruda and Opdivo for nasopharyngeal cancer effective 6/18/2025.

Added step therapy requirements for immune globulin products effective 11/1/2024.

Revised 2026-01-21document revision date

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Coverage criteria and condition summaries

Initial coverage conditions (examples from excerpt)

Covered when specified prior authorization and step therapy conditions are met for each drug entry

Orencia (J0129): Trial and failure of Inflectra or Avsola AND trial and failure of Steqeyma, Pyzchiva or Wezlana are required before coverage of J0129 (abatacept / Orencia).

Prior authorization effective dates vary by plan; submit via the Medical and Pharmacy Drug PA Portal.

Eylea (J0177/J0178): Trial and failure of bevacizumab (Avastin) or a bevacizumab biosimilar is required before coverage of ranibizumab/aflibercept-coded retinal agents as noted in the list.

Submit authorization request through the Medical and Pharmacy Drug PA Portal as indicated per code.

Denosumab (J0897): Use of preferred denosumab biosimilars (e.g., Stoboclo for Prolia or Osenvelt for Xgeva) is specified; step therapy applies and preferred biosimilars may not require prior authorization depending on product and date.

See prior authorization effective dates for specific entries (e.g., Xgeva entry noted 12/1/2025).

Complement inhibitors and related biologics (J1299, J1303): For indications such as myasthenia gravis, NMOSD, PNH and aHUS, trial and failure of the listed alternative biologics or biosimilars (detailed per indication) is required before coverage of the specified complement inhibitor or related agent.

Submit authorization request through the Medical and Pharmacy Drug PA Portal as indicated.

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