Use preferred products first; exceptions allow non‑preferred

Preferred products listed for each drug class are considered medically necessary when prescribed for FDA‑approved indications or uses accepted in CMS‑approved compendia; only preferred products are considered medically necessary unless the member has a documented contraindication/intolerance/adverse response to all preferred products, has used all preferred products with minimal clinical response, or has been on the requested therapy within the last 365 days.

Prior authorization required for non‑preferred therapies; step therapy applies in listed settings

Prior authorization is required for non‑preferred medical‑benefit therapies under Blue Cross of Idaho Medicare Advantage, and step therapy will be required when medications are administered under the member's medical benefit in outpatient/infusion/home settings; coverage of a non‑preferred product requires meeting a step‑therapy exception.

• Step therapy applies in: clinician/physician office; home health; home infusion; outpatient hospital and dialysis; surgical day care.
• If a non‑preferred therapy is given without prior authorization, the claim may be denied.

PA decisions tied to listed HCPCS / Q‑codes for bevacizumab/biosimilars

Prior authorization and coverage determinations will reference the HCPCS J‑ and HCPCS Q‑codes shown in the codes appendix to identify bevacizumab and its biosimilars (e.g., J9035 and adjacent Q‑codes) when adjudicating claims.

• Examples: J9035 (bevacizumab) and Q5107/Q5118/Q5126/Q5129/Q5160 for bevacizumab biosimilars.

PA applies to listed injectable specialty drugs and their J‑codes

Prior authorization applies to the injectable specialty drugs listed by J‑codes and associated entries in the coding appendix; examples include treprostinil (J3285), infliximab (J1745) and hyaluronan viscosupplementation J‑codes.

• Treprostinil: J3285 (Injection, treprostinil, 1 mg).
• Infliximab: J1745.
• Hyaluronans: J7318, J7320–J7323, etc.

Reference specific HCPCS/J and Q‑codes for PA and billing

Use the enumerated HCPCS/J and Q‑codes in the codes section when requesting authorization or submitting claims for viscosupplements and injectable biologics—these exact codes are used for billing and authorization lookups.

• Viscosupplementation examples: J7318, J7320, J7321, J7322, J7323.
• Biologic examples: J9355, J1745, J3285.

PA and coverage depend on the exact HCPCS/Q/NDC mappings

Prior authorization requirements and coverage status are influenced by the specific HCPCS/Q‑codes and NDCs enumerated in the appendix; the document maps codes (e.g., J3285, J1745 and multiple Q‑codes) to preferred/non‑preferred listings.

• Treprostinil mapping: J3285 plus multiple preferred and non‑preferred NDCs.
• Infliximab mapping: J1745 and biosimilar Q‑codes (Q5103/Q5104/Q5121).

PA covers listed J‑ and Q‑coded injectable products (e.g., hyaluronans, treprostinil)

Prior authorization applies to many injectable products identified by J‑ and Q‑codes in the coding appendix; hyaluronan viscosupplements and treprostinil are among the products listed with J‑codes that should be used for authorization requests.

• Hyaluronans: J7318, J7320–J7325.
• Treprostinil: J3285 and listed NDCs.

Submit matching HCPCS/Q/J codes with PA requests

When requesting prior authorization for specialty injectables, submit the correct HCPCS/Q/J code and supporting documentation that corresponds to the administered product as listed in the codes appendix; authorizations are code‑driven.

• Examples of codes to include: J3285 (treprostinil), J1745 (infliximab) and applicable Q‑codes for biosimilars.
• Providers must match the claim/authorization code to the specific product/NDC submitted.

Codes map to coverage categories — use the exact code shown

HCPCS/Q‑codes listed for infliximab, hyaluronan viscosupplements, trastuzumab and treprostinil are used to classify coverage (preferred, non‑preferred, biosimilar); ensure the code submitted matches the payer's listed classification to avoid processing issues.

• Infliximab codes: J1745 and biosimilar Q‑codes (Q5103, Q5104, Q5121).
• Hyaluronan codes: J7318, J7320, J7321, J7325, J7326.

New non‑preferred denosumab Q‑codes effective 04/01/2026

Coding updates effective 04/01/2026 added Q5161 and Q5162 as new non‑preferred denosumab product codes; use these codes per the updated code list when seeking authorization or submitting claims.

• Q5161 and Q5162 added as non‑preferred denosumab codes effective 04/01/2026.

Step therapy exceptions that allow non‑preferred coverage

Coverage of non‑preferred products requires meeting one of the explicit exceptions: trial and minimal response to ALL preferred products, contraindication/intolerance/adverse events to ALL preferred products, lack of FDA‑approved indication for preferred product, or continuation of prior therapy within the past 365 days.

• History of use of ALL preferred products with minimal clinical response.
• Documented contraindication/intolerance/adverse events to ALL preferred products.
• Preferred product lacks FDA indication for the requested use.
• Continuation of prior therapy within the last 365 days.

Documentation required to satisfy non‑preferred step therapy criteria

To obtain coverage for a non‑preferred product, document one of the allowed step‑therapy criteria (failure of all preferred agents, contraindication/intolerance to all preferred agents, preferred product lacks FDA indication, or member continuation within 365 days).

• Demonstrate history of use of ALL preferred products with minimal response.
• Provide documentation of contraindication/intolerance/adverse events to ALL preferred products.
• Show FDA indication gap for preferred product or evidence of prior use within 365 days.

Preference status may change PA and coverage decisions

Preferred versus non‑preferred designations are shown for some agents (for example treprostinil and certain NDC groups); these preference labels may affect prior authorization and utilization management decisions.

• Treprostinil NDC groupings are labeled Preferred or Non‑Preferred in the codes appendix.
• Expect utilization controls when NDCs are designated Non‑Preferred.

Biosimilar vs originator listings may imply step/substitution expectations

Biosimilar listings alongside originator products suggest the plan may favor specific biosimilars or apply product‑preference rules that can imply step or substitution expectations.

• Examples: infliximab biosimilars (Inflectra Q5103, Renflexis Q5104, AVSOLA Q5121) are listed separately from branded infliximab entries.
• Pegfilgrastim biosimilars and originator are enumerated with Q‑codes and some lines note 'excludes biosimilar'.

Treprostinil NDC groupings indicate potential preference/step edits

Preferred vs Non‑Preferred NDC groupings for treprostinil are explicitly differentiated in the code lists, implying plan‑level preference or step edits may control dispensing and coverage.

• Preferred treprostinil NDCs: e.g., 00781‑3420‑80, 00781‑3425‑80, 00781‑3427‑80, 00781‑3430‑80.
• Non‑Preferred examples include NDCs in the 66302‑xxxx series (66302‑0101‑01, 66302‑0102‑01, 66302‑0105‑01, 66302‑0110‑01).

Originator vs biosimilar coding is tracked separately

The code lists separate originator biologics from biosimilars (for example branded infliximab versus its biosimilars), which reflects that the payer may track and manage biosimilars and reference products separately when authorizing or adjudicating claims.

• Infliximab originator entries include 'excludes biosimilar' language while biosimilars have distinct Q‑codes (Q5103/Q5104/Q5121).

Preferred designations guide product selection for coverage

Preferred versus non‑preferred designations are indicated in multiple drug listings (e.g., treprostinil and infliximab) and may be used to determine which product should be tried first for coverage to be approved.

• Providers should select preferred NDCs/HCPCS when possible to minimize need for exceptions.
• Non‑preferred designations require documented exception criteria for coverage.

Follow preferred/non‑preferred annotations in the code appendix

Some product entries are explicitly marked Preferred or Non‑Preferred in the codes appendix; providers should use the listed preferred product when clinically appropriate or document an allowed exception to request non‑preferred coverage.

• Example: branded versus biosimilar infliximab listings show differing annotations that can affect coverage.

Payer tracks biosimilars and originators separately

Both biosimilar and originator products are listed with distinct HCPCS and Q‑codes; the payer may monitor and manage these separately for authorization and claims processing.

• Examples: infliximab and its biosimilars (Q5103/Q5104/Q5121) are enumerated alongside J1745.

Policy applies to Medicare Advantage Part B step therapy program

The document header references 'Medicare Advantage Part B Medical Drugs Step Therapy' indicating a step‑therapy program governs Part B medical drugs for Medicare Advantage members; detailed operational rules are located in the policy but are not fully reproduced in this excerpt.

Document prior use, intolerance, indication gaps or 365‑day continuation for non‑preferred coverage

To support coverage of a non‑preferred product, providers must document history of prior use of preferred products, documented intolerances/contraindications/adverse events to preferred products, lack of FDA indication for the preferred product, or evidence of continuation of prior therapy within the past 365 days.

• Include clinical notes documenting trials and responses to all preferred agents.
• Document adverse events or contraindications to preferred agents.
• Provide dates or paid claim evidence showing therapy continuation within 365 days.

Expect to provide clinical documentation with PA requests

A general documentation header is present in the policy; providers should expect to supply clinical documentation when requesting exceptions or prior authorization, though detailed submission forms/processes are not included in this excerpt.

Provide treprostinil NDC(s) when requested

National Drug Codes for treprostinil formulations are listed in the codes appendix; when required by the payer, providers should supply the exact NDC on the claim or authorization request to reflect preferred versus non‑preferred status.

• Preferred treprostinil NDC examples: 00781‑3420‑80, 00781‑3425‑80, 00781‑3427‑80, 00781‑3430‑80.

Include exact NDC or HCPCS when billing treprostinil

When billing treprostinil or similar agents, include the specific NDC or the listed HCPCS/brand code so the claim matches the payer's preferred/non‑preferred mapping and to support correct adjudication.

• Example: include J3285 and the exact NDC on the claim to reflect preferred vs non‑preferred status.

Claims must include exact NDC and HCPCS/Q codes from the appendix

Submit the exact NDC and HCPCS/Q‑code listed in the codes appendix for treprostinil and related agents to ensure the payer can match the product to its preferred/non‑preferred designation.

• Claims should list the HCPCS J3285 for treprostinil and the precise NDC from the appendix.
• Mismatched or missing NDC/HCPCS may result in processing delays or non‑preferred handling.

Submit the exact code/NDC that matches the administered product

Providers must submit the specific HCPCS/HCPCS‑like code or NDC that corresponds to the administered product as listed (for example, J3285 for treprostinil); mismatches can affect coverage classification.

• Example codes: J3285 (treprostinil), J1745 (infliximab) and applicable Q‑codes for biosimilars.

Use listed treprostinil NDC examples on claims/PA requests

Examples of treprostinil NDCs are provided in the policy; when required for claims or authorization, include these exact NDC values (e.g., 00781‑3420‑80, 00781‑3425‑80, 00703‑0666‑01) to reflect the product's preferred or non‑preferred status.

• Examples: 00781‑3420‑80; 00781‑3425‑80; 00703‑0666‑01; 42023‑0206‑01.

Document exact treprostinil/Remodulin NDC on claims

National Drug Codes for treprostinil and Remodulin are enumerated throughout the code appendix; include the exact NDC on claims to match the policy's preferred/non‑preferred groupings when requesting authorization or billing.

• Multiple NDCs are grouped as Preferred or Non‑Preferred—select and report the exact NDC used.

Use the codes appendix to match product codes and NDCs for PA/claims

The codes appendix is a detailed coding list that associates drug products, biosimilars, NDCs and HCPCS/Q‑codes; use this appendix entries when preparing authorization requests and claims, recognizing that operational PA text may be located elsewhere in the policy.

Non‑preferred requests may be denied without documented exceptions

Requests for non‑preferred products may be denied unless the member meets one of the policy's step‑therapy exceptions (failure of all preferred products, contraindication/intolerance to all preferred products, lack of FDA indication for a preferred product, or continuation within 365 days).

• If exception criteria are not met, the non‑preferred request may be declined.

Administering non‑preferred therapy without PA risks claim denial

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

• Obtain preservice prior authorization for non‑preferred medical‑benefit therapies to avoid denial risk.

Coding mismatches (HCPCS/Q) can trigger denials or special handling

Claims may be denied or require special handling if submitted with incorrect HCPCS/Q‑codes or if biosimilar versus reference‑product coding is inconsistent with the payer's listings; ensure coding matches the policy appendix entries.

• Check that biosimilar Q‑codes or originator J‑codes used on claims match the product actually administered.

Non‑Preferred NDCs can trigger coverage restrictions

Use of non‑preferred NDCs or product presentations listed as Non‑Preferred may trigger coverage restrictions or require prior authorization per the code appendix.

• Non‑Preferred NDC examples include 66302‑0101‑01, 66302‑0102‑01, 66302‑0105‑01, 66302‑0110‑01.

Non‑preferred NDCs/presentations increase denial risk

Use of non‑preferred NDCs or non‑preferred product presentations (for example certain treprostinil NDC groups) may be designated Non‑Preferred and could lead to coverage restriction or denial if exception criteria are not documented.

Mismatch between submitted code/NDC and payer mapping may cause denial

Claims may be denied or require different processing if the submitted NDC or HCPCS code does not match the payer's preferred/non‑preferred mapping for the product (for example, treprostinil NDC groupings).

Non‑Preferred products may be denied without documented exceptions

Use of products listed as Non‑Preferred (for example certain treprostinil NDC packs flagged Non‑Preferred) may trigger coverage restrictions or denial depending on formulary status and lack of documented exceptions.

Specific listed non‑preferred codes will receive non‑preferred handling

Use of non‑preferred NDCs/HCPCS (for example the listed non‑preferred codes such as 66302‑0101‑01, 66302‑0102‑01, 66302‑0105‑01, 66302‑0110‑01) may result in non‑preferred coverage handling.

Codes appendix shows lists and history; use payer PA process for submissions

This coding appendix excerpt includes codes and policy history but does not enumerate the specific operational prior authorization forms or exact submission steps; follow payer prior authorization processes and use the code appendix to match submitted codes.