Preferred-product prior authorization requirement

Only preferred products listed for a drug class are considered medically necessary for Blue Cross of Idaho Medicare Advantage Plan members; requests for non-preferred products require documentation of a qualifying exception (documented contraindication, intolerance, or adverse response to all preferred products; history of use of all preferred products with minimal clinical response; or the member has been on the requested therapy within the last 365 days).

• Preferred products named in each drug class (e.g., Avastin, Zirabev; Dysport, Botox; Hyalgan, Hymovis, Hymovis One, etc.) are the medically necessary choices.
• Non-preferred product approval requires meeting one of the exception criteria listed above.

Prior authorization and step therapy for non-preferred viscosupplements

Prior authorization and step therapy apply to non-preferred viscosupplement products under Medicare Advantage Part B: only preferred viscosupplements are considered medically necessary unless an exception is documented (contraindication/intolerance/adverse response to all preferred products; failure of all preferred products; or member on requested therapy within past 365 days).

• Step therapy and preservice authorization are required when these medications are administered under the member's medical benefit in outpatient settings (office, home health, home infusion, outpatient hospital and dialysis, surgical day care).
• Exceptions to the preferred requirement follow the non-preferred product criteria (see policy).

Prior authorization guidance — follow benefit documents

This policy does not prescribe a specific prior authorization submission process; providers must follow Blue Cross of Idaho benefit documents and the policy's coverage sections to determine the applicable prior authorization procedures for a given member.

• Coverage determinations and prior authorization requirements are subject to the member-specific benefit plan document.
• Identify member eligibility and the member-specific benefit plan before initiating prior authorization.

Step therapy enforcement across drug classes

The policy enforces preferred-product step therapy across multiple Medicare Advantage Part B medical drug classes: providers should prescribe preferred products first and obtain prior authorization for non-preferred products unless an exception is met.

• Prescribe preferred product(s) for the drug class unless documented exception criteria are satisfied.
• Step edits will be applied consistent with the policy and utilization management systems.

Criteria permitting non-preferred product coverage

Non-preferred products may be covered only when one of the policy's step-therapy exception criteria is met: history of use of ALL preferred products with minimal clinical response; documented contraindication, intolerance, or adverse event(s) to ALL preferred products; or other documented medical reasons such as continuation of prior therapy within the last 365 days.

• A paid claim within the past 365 days for the requested therapy defines continuation of prior therapy.
• If preferred products lack an FDA-approved indication for the use, that may also permit non-preferred coverage per the policy.

Step therapy and product preference updates (policy history)

Policy history documents product preference and coding changes that may affect current step edits and product-preference enforcement; providers should verify current formulary/preference status before prescribing non-preferred agents.

• Recent history includes additions/removals of preferred and non-preferred products (e.g., Jobevne added as non-preferred bevacizumab; Hymovis One added as preferred viscosupplement).
• Coding updates effective 4/1/26 and 9/1/26 added several denosumab and other codes which may change step-edit behavior.

Verify member eligibility and benefit plan

Before applying this medical policy, identify member eligibility and the member-specific benefit plan; the member-specific benefit plan supersedes this medical policy when there is a conflict.

• Confirm the line of business—this policy applies to Medicare Advantage Part B only.
• Review related policies and the member's coverage terms prior to authorization or administration.

Documentation — support exceptions and prior authorization

Maintain clinical documentation per the policy's Documentation Requirements heading to support requests for non-preferred product coverage or continuation of therapy; the policy references documentation but does not list granular items in this section.

• Document prior trials, clinical response, contraindications/intolerances, and dates of prior therapy (to establish the 365‑day lookback).
• Retain records to support any prior authorization determinations.

Coding guidance note — codes are for reference only

Coding lists in the policy are provided for general reference only; inclusion of a code in the policy does not guarantee coverage or reimbursement—providers must follow member-specific benefit documentation and other applicable policies when submitting claims.

• Use the member's benefit plan and current coding guidance to determine billable codes and reimbursement.
• Policy coding tables do not replace benefit verification requirements.

Denial risk for non-preferred requests without exceptions

Requests for non-preferred products may be denied unless the member meets an allowed exception: documented contraindication/intolerance/adverse response to all preferred options; trial and inadequate response to all preferred products; or continuation of the requested therapy within the prior 365 days.

• Denial risk applies when non-preferred agents are requested without supporting documentation of these exceptions.
• Providers should include clinical rationale and evidence of prior trials when submitting authorizations.

Denial risk for non-authorized non-preferred therapy

If a provider administers a non-preferred therapy without obtaining prior authorization, Blue Cross of Idaho may deny claims for the non-authorized therapy.

• Obtain prior authorization before administering non-preferred medical-benefit drugs in applicable outpatient settings to avoid claim denials.
• This prior authorization requirement applies to all Medicare Advantage Plans.

Coverage contingent on member-specific benefit plan

Inclusion of a code in this policy's coding tables does not guarantee coverage or reimbursement; all coverage determinations are subject to the member-specific benefit plan document and other applicable policies and legal requirements.

• Verify coverage and reimbursement with the member's benefit plan before ordering or billing.
• Coding updates in the policy history (effective dates noted) may change coding options and preferences.

Preservice authorization required for outpatient medical benefit settings

When medications are administered under the member's medical benefit in outpatient settings (clinician/physician office, home health, home infusion, outpatient hospital and dialysis, or surgical day care), step therapy/preservice authorization is required.

• Clinician or physician office
• Home health care provider
• Home infusion therapy provider
• Outpatient hospital and dialysis settings
• Surgical day care

Bevacizumab (Jobevne) listed as non-preferred

Policy history lists Jobevne (bevacizumab-nwgd) as a non-preferred product added to the bevacizumab category.

Denosumab biosimilar codes added as non-preferred

Coding updates added multiple denosumab biosimilar codes (example: Q5161, Q5162, and later Q5165, Q5166, Q5167, Q5171) which the policy indicates as non-preferred denosumab products in the coding section.

Policy history may alter step therapy/product preference

Policy history documents changes to preferred and non‑preferred products across categories (e.g., toxins, infliximab, denosumab, bevacizumab) and coding updates; these history entries may affect current step edits and product preference enforcement.