2026 Prior Authorization and Step Therapy for Medicare Plus Blue PPO Plans (PDF)
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Part 1 of 6 of BCBS Michigan Medicare Plus Blue PPO 2026 formulary prior authorization and step therapy criteria listing specific drugs with per-drug PA/ST status, coverage durations, prerequisite therapy requirements, indication-specific requirements, age/prescriber restrictions and reauthorization expectations.
No material clinical or coverage changes reported in this brief (has_material_change=false).
Coverage Summary
BCBSM Medicare Plus Blue PPO monitors use of certain medications to ensure members receive the most appropriate and cost-effective drug therapy. Prior authorization (PA) must be requested and approved prior to coverage when indicated. Drugs subject to step therapy (ST) require prior treatment with one or more formulary drugs. The clinical criteria used for authorization reflect current medical evidence and P&T Committee recommendations.
General PA/ST program rules (introductory)
General PA/ST program rules (introductory). Covered when ALL of the following are met:
ALL of the following
- A prior authorization or step therapy request is submitted before the drug claim is processed.
- Documentation supplied by the prescriber supports the specific indication and required baseline/ongoing clinical information per product-specific criteria.
- If the product is subject to step therapy, documentation shows trials and treatment failure of the required formulary alternatives (Part D drugs) unless an allowed exception is provided.
- For biologic or targeted DMARDs, the patient is not receiving concurrent biologic therapy for the same condition unless explicitly allowed by the product criteria (many biologics exclude combination use with another biologic/targeted DMARD).
- Coverage duration limits (commonly 1 YEAR) and reauthorization requirements (documentation of positive clinical response) are acknowledged and will be monitored at renewal.
- Where product-specific age, prescriber, or diagnosis restrictions exist, those requirements are met (examples: age >=12 for certain agents).
- Quantity limits, dose caps, or weight-based dosing restrictions are followed (examples: Adbry dosing limitations for patients <100 kg).
- Exclusion criteria defined for the product are not met (e.g., contraindications, prohibited combinations).
- When a prerequisite Part D drug is required, the member has tried and failed or is intolerant to the specified agent(s), unless a documented contraindication or exception applies.
Initial Therapy Criteria (per-product)
Per-product prior authorization / step therapy criteria (excerpted entries)
Per-product prior authorization / step therapy criteria — each product entry lists indication-specific requirements, exclusions, required medical information, coverage duration, reauthorization rules, and whether a prerequisite Part D drug is required. Product-level entries are rendered as child nodes under this group; 'any' operator used where product list is a selection.
Product entries (excerpt) - selection
- Adbry: Coverage for atopic dermatitis (age ≥12): diagnosis of moderate-to-severe AD and trial/failure of one of: high-potency topical corticosteroid, tacrolimus, pimecrolimus, cyclosporine, azathioprine, or mycophenolate mofetil; reauthorization requires documentation of positive clinical response; requires prerequisite Part D drug.
- Cosentyx: All medically-accepted indications; exclusion: cannot be used with another biologic/targeted DMARD for same condition; indication-specific trials (eg AS requires NSAID trial); reauthorization requires documentation of positive clinical response; requires prerequisite Part D drug.
- Dalfampridine Er: All indications; excluded if patient is wheelchair bound or becomes wheelchair bound; requires submission of baseline Timed 25-Foot Walk (T25FW) prior to initiation; reauthorization requires documentation of stability or improvement on T25FW; does not require prerequisite Part D drug.
- Dupixent: Multiple indications with indication-specific criteria (age limits, eosinophil thresholds for EA, failure of prior controllers for EA/CDA, CRSwNP recurring despite intranasal steroids, EOE requires trial of PPI or topical esophageal corticosteroid); exclusion: cannot be used with another biologic/targeted DMARD for same condition; reauthorization requires documentation of positive clinical response; requires prerequisite Part D drug.
- Epidiolex: Coverage duration 1 year; Lennox-Gastaut requires trial of 2 generic alternatives; Dravet requires trial of 2 of: valproic acid, clobazam, or topiramate; requires prerequisite Part D drug.
- Dihydroergotamine Mesylate SOLN: Coverage requires trial of two triptans on formulary: one oral and one non-oral (eg nasal or injection); requires prerequisite Part D drug.
- Fasenra: All medically-accepted indications; exclusion: cannot be used with another biologic/targeted DMARD for same condition; EGPA requires two typical EGPA criteria; EA requires eosinophil ≥150 cells/µL at initiation and failure to maintain control after prior therapy; reauthorization requires documentation of positive clinical response; requires prerequisite Part D drug.
- Praluent: Indication-specific confirmation (ASCVD, Primary HLD, HeFH, HoFH) with LDL/statin requirements while on high-intensity statin (LDL ≥55 mg/dL with ASCVD; LDL >70 mg/dL without ASCVD); statin therapy requirements (12 weeks high-intensity statin or intolerance after trials of atorvastatin and rosuvastatin); HoFH genetic or LDL thresholds; coverage duration: 3 years; reauth requires continued statin/other lipid therapy and documented LDL reduction while on Praluent; requires prerequisite Part D drug.
- Retevmo: Coverage for RET fusion-positive NSCLC and other RET-altered tumors per FDA-approved tests; coverage for thyroid RET-fusion tumors requires trial/failure with radioactive iodine if appropriate; requires prerequisite Part D drug.
Continuation / Reauthorization Criteria
Reauthorization requires documentation of positive clinical response
Reauthorization and renewal logic present in multiple product entries — reauthorization generally requires documentation of positive clinical response; some products have specific measurable renewal criteria.
Examples: Cosentyx, Dupixent, Enbrel, Orencia, Rinvoq, Nucala, Skyrizi indicate reauthorization requires documentation of positive clinical response.
Coverage duration 3 years for Praluent
Coverage duration 1 year
Exclusions and Not Covered Scenarios
Explicit exclusions and denial conditions (leaf criteria)
Explicit exclusions and denial conditions are specified in product entries; these are rendered as leaf 'Exclusion' criteria where present.
Exclusions / Denials - selection
- Dalfampridine exclusion: Excluded for use if patient is wheelchair bound or becomes wheelchair bound.
Requires baseline T25FW submission and reauthorization requires stability or improvement on T25FW.
- Tadalafil exclusion: Coverage is not provided for tadalafil when patients are receiving nitrate therapy (nitrate co-administration excluded).
Requires diagnosis of benign prostatic hyperplasia for covered uses.
- Xifaxan indication-specific prior trials (coverage prerequisites): Coverage for hepatic encephalopathy requires trial of lactulose; IBS-D requires trial of at least one of loperamide, dicyclomine, or diphenoxylate/atropine; recurrent C. difficile requires trial of vancomycin — failure to meet these prerequisite trials may preclude coverage.
- Biologic combination exclusions: Many biologic/targeted DMARD entries explicitly exclude concomitant use with another biologic or targeted DMARD for the same condition (e.g., Cosentyx, Dupixent, Nucala, Xolair, Tocilizumab, others).
- Sodium Oxybate exclusions: Coverage is not provided for patients taking sedative hypnotics or patients with succinic semialdehyde dehydrogenase deficiency.
Also requires prior trials for narcolepsy-related indications.
Formulary Identifiers / Product List (codes)
| Formulary ID: 26449 | Formulary identifier listed in document |
| Version: 17 | Formulary version |
| Effective Date: 06/01/2026 | Formulary effective date (listed multiple times) |
| Formulary ID: 26449 | Plan formulary identifier and version |
| Orencia Formulary ID: 26449; Version: 17; Effective Date: 06/01/2026 | Orencia product header/footer metadata as shown in document |
| Orencia INJ 125MG/ML | Product listed |
| Orencia Clickject | Product listed |
| Posaconazole Dr | Product listed |
| Praluent | Product listed |
| Prevymis PACK | Product listed |
| Prevymis TABS | Product listed |
| Retevmo | Product listed |
| Rinvoq | Product listed |
| Skyrizi INJ 150MG/ML | Product listed |
| product_list | Abelcet; Acetylcysteine INHALATION SOLN; Acyclovir Sodium INJ 50MG/ML; Albuterol Sulfate NEBU (multiple strengths); Amphotericin B INJ; Amphotericin B Liposome; Aprepitant; Astagraf XL; Azathioprine TABS 50MG; Budesonide SUSP; Cromolyn Sodium NEBU; Cyclophosphamide CAPS; Cyclosporine CAPS; Cyclosporine Modified; Dronabinol; Engerix-b; Everolimus TABS (0.25,0.5,0.75,1 mg); Gengraf CAPS (100mg,25mg); Gengraf SOLN; Granisetron Hydrochloride TABS; Heplisav-b; Imovax Rabies (h.d.c.v.); Intralipid INJ 20GM/100ML; Ipratropium Bromide INHALATION SOLN 0.02%; Ipratropium Bromide/albuterol Sulfate; Mycophenolate Mofetil CAPS/SUSR/TABS; Mycophenolic Acid Dr; Ondansetron Hcl SOLN 4MG/5ML; Ondansetron Hydrochloride TABS; Ondansetron ODT (4mg, 8mg); Premasol INJ (multiple concentrations); Prograf PACK; Prosol; Pulmozyme SOLN 2.5MG/2.5ML; Rabavert; Recombivax Hb; Sirolimus SOLN/TABS; Tacrolimus CAPS; Tobramycin NEBU 300MG/5ML; Travasol INJ (multiple concentrations); Ventavis; (and many others listed separately in document e.g., Xeljanz, Xolair, Xifaxan, etc.) |
Provider Actions / What Providers Must Do
Prior Authorization Required
Prior authorization (PA) is required for many listed products. Check the formulary for product-specific PA requirements and submit a PA prior to dispensing when indicated.
- Prior authorization required per product — verify each drug in the Formulary (PA).
- Prior authorization required for listed products includes biologics, specialty drugs, and certain injectables (see Formulary).
Step Therapy Required
Some drugs are subject to step therapy; a trial of one or more specified formulary agents is required before coverage of the requested drug.
- Step therapy / prerequisite drug trials required for many products.
- Required trial of specified generics or alternative agents may apply (see individual drug criteria).
Submit Required Clinical Documentation
Submit clinical documentation to support the request: indication-specific information, prior therapy trials and intolerances, diagnostic confirmation, and relevant lab/phenotyping data.
- Document indication-specific clinical information and diagnostic confirmation for select products (e.g., genetic/phenotype results, disease staging).
- Document prior therapy trials, dates, durations, and reasons for failure or intolerance.
- Submit required clinical documentation such as lab values, imaging, pulmonary function tests, A1c or glucose data for diabetes therapies, and phenotyping where applicable.
Reauthorization and Coverage Durations
Reauthorizations typically require demonstration of ongoing clinical benefit. Coverage durations are commonly 1 year; request renewals with documentation of positive clinical response.
- Reauthorization requirements: reauthorization requires documentation of response and demonstration of clinical benefit.
- Reauthorization must show clinical benefit/positive clinical response; reauthorization documentation of response is required.
- Coverage durations and renewals: most approvals are for one year — include clinical response data when requesting renewal.
Age and Prescriber Restrictions
Age and prescriber restrictions may apply; some products require specialists or minimum age (e.g., Adbry age ≥12). Check product criteria for prescriber specialty requirements.
- Age and prescriber restrictions: follow product-specific limits (e.g., Adbry: at least 12 years of age).
- Common specialty prescriber restrictions: many specialty or oncology biologics require a specialist prescriber (oncology, rheumatology, dermatology, pulmonology, etc.).
IVIG / Medicare Billing Determination
IVIG and other immunoglobulin products may require Medicare Part B vs Part D determination and review for appropriate billing pathway.
- IVIG Part B vs Part D review: determine benefit alignment (Part B physician-administered vs Part D outpatient drug).
- Medicare Part B vs Part D determination must be clarified on submission to ensure correct coverage and billing.
Denial Risk — Missing Criteria or Documentation
Exclusions and failure to meet required trials/criteria can result in denials. Ensure documentation of required trials, intolerances, and diagnostic evidence to reduce denial risk.
- Denial risk: exclusion-based denials occur when clinical criteria, prerequisite trials, or documentation are absent.
- Provide complete documentation to avoid denials: trials of required prior therapies, lab evidence, and diagnostic confirmation.
Consolidated submission checklist: include indication-specific clinical notes, diagnostic confirmation (labs, imaging, genotyping/phenotyping where required), prior therapy trial records with dates and reasons for failure/intolerance, relevant laboratory values (for diabetes therapies include A1c/glucose and other disease-specific labs), prescriber specialty and patient age, and requested coverage duration (commonly 1 year) with documentation of expected/observed clinical benefit for reauthorization.
Clinical Evidence / Thresholds
The brief did not include a formal clinical evidence (literature) section (no evidence entries were provided). Nevertheless, the PA/ST criteria reference numeric clinical thresholds and guideline‑based trial requirements (for example, eosinophil counts, LDL thresholds, timed walk tests, and required prior therapy trials); see the thresholds and per-product criteria blocks for specific numeric and trial-based requirements.
Background
Background: this document is a section of the Meijer Core Comprehensive Formulary Prior Authorization / Step Therapy Program for BCBSM Medicare Plus Blue PPO for plan year 2026. It enumerates medications subject to prior authorization or step therapy and details the clinical and administrative criteria required for coverage (Formulary ID 26449, Version 17, Effective Date 06/01/2026).
Definitions / glossary: 'Prerequisite Part D drug' — a formulary or generic medication that must be tried and documented prior to approval of the requested non-formulary or higher-tier product (step therapy requirement). 'Prerequisite Part D drug required' — the policy flag indicating a product’s coverage requires prior use of one or more specified Part D therapies. 'Reauthorization' — renewal of approval that requires documentation of clinical response or other outcome measures as specified per drug entry.
Revision History
Formulary effective date: 06/01/2026 (Formulary ID 26449, Version 17).
Last reviewed/updated: 06/01/2026.
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