Prior authorization required; include affected HCPCS/CPT/Q/J codes

Prior authorization is required for medications listed in the step therapy table; requesters must document and request using the applicable HCPCS/CPT/Q/J codes associated with the requested product per the table.

• See the table rows pairing requested products with specific codes (e.g., J0256, Q5126, J9035, Q5130).

Request authorization using the correct drug/service code(s)

Prior authorization is organized around the listed HCPCS/CPT/J‑codes for each drug and step; providers must request authorization using the specific code(s) shown for the product and step.

• Examples of codes used in step mappings include Q5152, J9256, J1299, J1303.

Use the mapped HCPCS/J-code for PA tied to step position

When requesting prior authorization, use the HCPCS/J-code that corresponds to the listed product and its step position in the policy's step therapy mappings.

• The policy maps products to step positions 1–4 using specific J-codes (e.g., J1299, J1303, J7318, J7326).

Reference the listed HCPCS/Q/J codes on the authorization

Authorization requests should reference the listed HCPCS/J‑ and Q‑codes that correspond to the provider‑administered specialty product being requested to demonstrate alignment with the step table.

• Example codes shown for viscosupplements and infliximab include J7320–J7332 and Q5121/J1745.

PA tied to specific administration/product codes

Prior authorization and step‑therapy determinations reference specific HCPCS/CPT/J‑codes for provider‑administered biologics and related products; include those administration/product codes on PA requests.

• Examples: infliximab group codes (J1745, Q5121, Q5104) and pegfilgrastim codes (J1449, J9361, Q5130).

PA must include code-to-drug mapping

Prior authorization must reflect the specific HCPCS/CPT/J‑code(s) mapped to the requested specialty medication per the step therapy table; submit the code that identifies the exact product being requested.

• Mapped examples across sections include Q5130, Q5122, J1449, J9361 and many product-specific J/Q codes.

Include the specified product HCPCS/CPT/Q codes on PA

Prior authorization is organized around the specific HCPCS/CPT/Q‑codes listed for each agent; requests should include the exact code for the administered product as shown in the table.

• Retinal and PNH product examples reference codes such as J0179, J1303, J1307, Q5150 and others.

Code‑linked PA: administered drug must match approved code and step

Prior authorization requires that the administered drug matches an approved HCPCS/CPT/J/Q code and the step sequence in the policy; the PA should demonstrate that the product and code align with the listed step mapping.

• Ophthalmic groups show Avastin, Byooviz, Eylea and associated J/Q codes mapped to step positions (e.g., J2778, J0179, Q5153).

PA must use the listed drug HCPCS/CPT/Q/J codes

Prior authorization is organized around the listed J‑, Q‑ and other HCPCS/CPT codes for each specialty product grouping; providers must request authorization using those listed codes.

• Examples include J2779, J2777, Q5155, Q5147 and multiple rituximab/trastuzumab codes referenced in step lists.

Step therapy requirement: trial preferred alternative(s) first

Providers must trial one or more preferred alternative agent(s) listed in the table (column 2) prior to coverage of the requested product, unless otherwise noted in the table.

• The table states 'Must try one of the following unless otherwise noted' for requested products and lists preferred alternatives by name and code.

Follow numbered step‑therapy sequences by drug and code

The document lists numbered step‑therapy sequences (1–4, sometimes up to 5) for multiple provider‑administered specialty medications; authorization assessment follows the sequence and associated codes.

• Myasthenia gravis, viscosupplement, infliximab and other product families are presented with explicit step positions and codes.

Step therapy enforced via HCPCS/J‑code to step mapping

Step therapy is enforced by mapping specific HCPCS/J‑codes to step positions (1–4); providers must follow the mapped code‑to‑step relationships when requesting later‑step agents.

• The policy assigns J‑codes such as J7318, J7326, J7328, etc., to step positions across groups.

Step product groups enumerated (viscosupplements & infliximab)

Product groups such as viscosupplements and infliximab products are enumerated as step therapy product groups; providers should reference the group listings and associated codes when planning therapy.

• Viscosupplement codes include J7320–J7332; infliximab group includes Q5121 and J1745 among others.

Step listings present (product step positions shown, details partial)

Step positions are enumerated for many products (notably infliximab family and viscosupplements); the table shows products placed in positions 1–4 (details partial in this segment).

• Infliximab entries reference Avsola/Remicade/Inflectra with Q5121/J1745 and step numbers.

Follow drug-to-code step mappings as shown

Providers must follow the drug‑to‑code step mappings shown: each listed drug or drug group is associated with one or more step positions and specific HCPCS/CPT/J‑codes; use the mapped codes for authorization.

• Many mapped groups reference prior agents (e.g., Neulasta/Neulasta Onpro, Fulphila) and list corresponding J/Q codes to show sequencing.

Follow enumerated step therapy sequences (initial agent then alternatives)

Providers must follow the enumerated step therapy pairings where an initial agent is followed by 'Then one of the following' alternatives; the table lists initial agents and allowed alternatives for subsequent steps.

• Examples include Avastin/Lucentis groups where Avastin is followed by 'Then one of the following' lists (Byooviz, Eylea, Lucentis, etc.).

Adhere to enumerated step sequences; document prior steps

Providers must follow the step therapy sequencing where an initial agent (often Avastin or another lower‑step drug) is followed by listed alternatives at subsequent steps; authorization of later‑step agents requires documentation of prior steps.

• Ophthalmic groups list Avastin and then 'one of the following' alternatives with specific J/Q codes for each step position.

Step therapy sequencing follows code‑group based groupings

Coverage follows step therapy groupings where one listed product/code may be required prior to coverage of another; providers must reference the grouped code listings when requesting coverage.

• Grouped examples include rituximab/trastuzumab and ophthalmic biologic families with multi‑step code groupings.

Document provider‑administration, indication, and dosing justification

Documentation must demonstrate the medication is a provider‑administered specialty drug used for a medically accepted indication, and that dose, frequency, and duration align with the safety and efficacy data supporting that indication.

• The policy preface requires the drug be provider‑administered and used for a medically accepted indication with supported dose/frequency/duration.

Reference specific HCPCS/CPT/J‑code(s) and step number on PA

Prior authorization requests should reference the specific HCPCS/CPT/J‑code(s) corresponding to the drug and the step number to demonstrate adherence to the step therapy sequence.

• Include the step number from the table alongside the HCPCS/J‑code(s) listed for the product.

Submit the product‑specific HCPCS/J‑code on the authorization

Submit the appropriate HCPCS/J‑code that corresponds to the specific product being requested; authorizations should identify the exact product code rather than a generic or alternate code.

• Hyaluronic acid derivative examples show J7318, J7326, J7328, J7320, etc., assigned to specific products and steps.

Pair product name with the listed HCPCS J/Q codes on submissions

Use product names paired with their HCPCS J‑ and Q‑codes from the table when completing authorizations and billing to ensure requests match the policy's mappings.

• Examples in the document pair product names with codes (e.g., J7320–J7332, Q5121, J1745).

Ensure billing/authorization reference the policy's specific product code

Billing and authorization must reference the specific HCPCS/CPT/J‑code for the administered product as listed in the policy's step tables to support coverage determination.

• Examples include J1745/Q5121 for infliximab and multiple Q/J codes for pegfilgrastim and ophthalmic agents.

Present drug name/group with corresponding HCPCS/CPT/J code(s)

Providers must present the drug name/group and corresponding HCPCS/CPT/J‑code(s) that match the step therapy mapping when requesting authorization or submitting claims.

• The policy repeatedly requires aligning the drug/group name with the listed codes to match step positions.

Document prior agent(s) tried per 'Then one of the following' lists

Document the chosen agent and, where relevant, the prior agent(s) tried consistent with the 'Then one of the following' step lists to demonstrate that required prior steps were attempted.

• Ophthalmic and other groups show 'Then one of the following' lists—document prior agents accordingly.

Reference specific HCPCS/CPT/J/Q codes on claims/authorizations

Claims and authorizations must reference the specific HCPCS/CPT/J/Q codes corresponding to the administered specialty medication as listed in the step sequences.

• The document lists many specific J/Q codes (e.g., J2778, Q5153, J3396) that should be used on submissions.

Reference the policy's listed HCPCS/J/Q codes when seeking authorization

Provider authorization requests should reference the exact HCPCS/J‑codes or Q‑codes listed for the specialty product(s) when seeking authorization to ensure alignment with the policy.

• Ophthalmology and rituximab groups illustrate use of Q5153, Q5147, J2779 and related codes in step lists.

Denial risk if drug is not provider‑administered, indication unsupported, or dosing exceeds evidence

Requests may be denied if the medication is not a provider‑administered specialty drug, is not being used for a medically accepted indication, or if the requested dose/frequency/duration exceed supported safety and efficacy data.

• The policy preface lists these three primary coverage conditions as required for coverage.

Denial risk for mismatched HCPCS/CPT/J‑code and step sequence

Coverage may be determined by whether the requested HCPCS/CPT/J‑codes and the drug sequence align with the step entries listed for the condition; mismatched code or step alignment may lead to denial.

• Myasthenia gravis and other condition‑specific sequences require code/step alignment (examples show J9256, J9333, J1299 mapped to steps).

Denial risk if code does not match mapped step position/product

Submissions using HCPCS/CPT/J‑codes that do not match the mapped step position or product may be subject to denial if they do not conform to the policy's step mappings.

• The policy maps many J‑codes to step positions (e.g., J7318, J7326) and expects submissions to use those mapped codes.

Risk of processing discrepancies if product/code not matched (implicit denial risk)

The table lists products and codes without explicit denial rules in every chunk, but failure to match products/codes to the authorization request could lead to coding or authorization discrepancies.

• Where explicit denial language is not repeated, providers should still align requests to the listed mappings to avoid processing issues.

Claims may be subject to step therapy review when using listed HCPCS/CPT/J‑codes

Claims for listed provider‑administered specialty medications submitted using the listed HCPCS/CPT/J‑codes could be subject to step therapy review or processing aligned with the step listings shown in the policy.

• Infliximab and viscosupplement groups show code lists that are used to determine step therapy processing.

Nonconforming code or step mapping may trigger denial

Requests that do not follow the documented step mappings between drug/group and listed HCPCS/CPT/J‑codes may be subject to step therapy requirements and denial if prior steps are not met.

• The policy indicates prior‑agent requirements for many groups (e.g., pegfilgrastim, MS, NMOSD) and expects adherence to sequencing.

Denial risk for nonconforming step sequence or not using listed substitutes

Failure to follow the indicated step therapy sequence or to use one of the listed substitute agents (for groups that list 'Then one of the following') may result in denial unless an approved exception is obtained.

• Several 'Then one of the following' groupings require documentation of prior agents; exceptions are available per the plan's determination process.

Denial risk for use of non‑sequenced agents

Use of a non‑step agent or failure to follow the listed sequencing of agents as presented (e.g., not following 'Then one of the following' sequences) may trigger denial of coverage.

• Ophthalmic and biologic groups explicitly list ordered step sequences; do not substitute agents outside those lists without an exception.

Denial risk if step therapy not met — exception process available

Failure to follow the plan's step therapy requirements may result in denial unless an exception is requested and approved through the organization's determination process.

• Members may request an exception to the step therapy requirement; such requests are reviewed through the plan's determination process.