CurrentFlorida BluePolicy N/A

Part B Step Therapy Drug Program updates for Medicare Advantage

Describes additions and changes to Part B step therapy requirements for certain non-preferred, higher-cost medications for Florida Blue Medicare Advantage members; affects prescribing and prior authorization for Medicare Advantage Part B drug administrations.

Policy Summary

PayerFlorida Blue

PolicyPart B Step Therapy Drug Program updates for Medicare Advantage

Policy CodePolicy N/A

Change TypeAddition of drugs to Part B step therapy

Effective DateMay 15, 2023

Next Review Date

Key ActionApply step therapy only for new Part B prescriptions/administrations and obtain prior authorization when prescribing preferred alternatives as required by the plan.

SourceLink

POLICY UPDATE CHANGES

Additional drugs were added to the Part B step therapy programs effective May 15, 2023.

4therapeutic groups updated

multiplepreferred vs non-preferred drug products listed (includes J-/Q-/C- HCPCS codes)

2023-05-15effective date of change

Step Therapy and Medical Necessity Criteria

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ALL of the following must be met

Medication is listed as a non-preferred, higher-cost Part B drug in the step therapy program
Member is not actively receiving the affected medication (step therapy applies only to new prescriptions/administrations)
See policy note: step edits apply only to new prescriptions/administrations for enrollees not actively receiving the affected medication; most recent list maintained at MCG.bcbsfl.com
Definition of medical necessity must be met for coverage

Preferred-alternative expectation

Providers are encouraged to prescribe preferred alternatives where appropriate; pre-authorization may apply for the preferred alternative.

ONE of the following

Prescribe one of the listed preferred products for the therapeutic group instead of the non-preferred product
Preferred product examples include Q5107/Q5118 for Mvasi/Zirabev; Q5108/Q5111/Q5122/Q5120 and J1447/Q5101/Q5110 for colony stimulating factors; Q5106 for Retacrit; J3490/C9257 for bevacizumab
Obtain pre-authorization if required for the chosen preferred alternative
Some preferred products may still require prior authorization per plan rules

This update describes additions and changes to the Medicare Advantage Part B step therapy program for Florida Blue members. It affects prescribing, prior authorization, and claims/administration processing for certain higher-cost, non-preferred Part B medications by requiring step therapy for new prescriptions/administrations when the member is not actively receiving the affected medication and by mapping preferred and non-preferred products to HCPCS/Q/C and miscellaneous codes to support step edits and claims processing.

HCPCS / J-/Q-/C-code Groupings

Cancer and Supportive Therapy - Preferred productsHCPCS/Q/otherCovered

Q5107	Preferred product code for Mvasi / Zirabev
Q5118	Preferred product code for Mvasi / Zirabev

Cancer and Supportive Therapy - Non-preferred productsHCPCS/CPT/other

Avastin	Non-preferred for oncology diagnosis only (brand name)
Alymsys	Non-preferred
Vegzelma	Non-preferred
J9035	Bevacizumab HCPCS (example non-preferred grouping)
C9142	Bevacizumab HCPCS
Q5126	Bevacizumab Q-code
Q5129	Bevacizumab Q-code
C9399	Miscellaneous drug code listed as non-preferred

Colony Stimulating Factors - Preferred productsHCPCS/QCovered

Q5108	Preferred product code for Fulphila
Q5111	Preferred product code for Udenyca
Q5122	Preferred product code for Nyvepria
Q5120	Preferred product code for Ziextenzo
J1447	Preferred product HCPCS for Granix
Q5101	Preferred product code for Zarxio
Q5110	Preferred product code for Nivestym

Colony Stimulating Factors - Non-preferred productsHCPCS/Q

Neulasta	Non-preferred product (brand)
Fylnetra	Non-preferred product
Rolvedon	Non-preferred product
Stimufend	Non-preferred product
J2505	Neulasta HCPCS (listed as non-preferred)
Q5130	Associated non-preferred code
J1449	Associated non-preferred HCPCS
Q5127	Associated non-preferred Q-code
J1442	Non-preferred HCPCS (Granix/related group)
Q5125	Non-preferred Q-code

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Erythropoiesis Stimulating Agents - Preferred productHCPCS/QCovered

Q5106

Preferred product code for Retacrit

Erythropoiesis Stimulating Agents - Non-preferred productsHCPCS/J-codes

Procrit/Epogen	Non-preferred (step therapy does not apply until shortage is resolved)
Aranesp	Non-preferred
Mircera	Non-preferred
J0885	Associated non-preferred HCPCS/J-code
J0881	Associated non-preferred HCPCS/J-code
J0887	Associated non-preferred HCPCS/J-code

Ophthalmic Agents - Preferred productHCPCS/CPT/miscCovered

J3490	Bevacizumab listed as preferred product (unclassified drug code)
C9257	Bevacizumab C-code listed as preferred

Ophthalmic Agents - Non-preferred productsHCPCS/J/other

Beovu	Non-preferred ophthalmic agent
Byooviz	Non-preferred ophthalmic agent
Cimerli	Non-preferred ophthalmic agent
Eylea	Non-preferred ophthalmic agent
Lucentis	Non-preferred ophthalmic agent
Macugen	Non-preferred ophthalmic agent
Susvimo	Non-preferred ophthalmic agent
Vabysmo	Non-preferred ophthalmic agent
Visudyne	Non-preferred ophthalmic agent
J0179	HCPCS listed among non-preferred codes

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What Providers Must Do

Prior Authorization

Prior authorization may be required for preferred alternatives

Providers should obtain pre-authorization when prescribing preferred alternatives, as some preferred products may still require PA per plan rules.

Step Therapy

Step therapy applies to new Part B prescriptions/administrations

Apply step therapy only for enrollees not actively receiving the affected medication; it applies to new Part B prescriptions or administrations and new starts on listed non-preferred drugs must try preferred alternatives first.

Documentation Required

Meet definition of medical necessity

Coverage for non-preferred higher-cost medications requires documentation that the plan's definition of medical necessity is met.

Documentation must show the plan's definition of medical necessity is met.
Note: step edits for Procrit/Epogen are suspended until the shortage is resolved (step therapy does not apply during the shortage).

Clinical and Program Background

Florida Blue updated its Part B step therapy program effective May 15, 2023 to encourage use of lower-cost preferred biologics/agents and to map preferred and non-preferred products to HCPCS/Q/C and miscellaneous codes to support claims processing and step edits. The therapeutic groups added or updated include oncology/supportive care (bevacizumab/Mvasi/Zirabev), colony stimulating factors, erythropoiesis stimulating agents, and ophthalmic agents, with associated preferred codes such as Q5107, Q5118, Q5108, Q5111, J1447, Q5106, J3490, C9257 and non-preferred codes/groups including brand names and HCPCS/Q/C codes (examples: Avastin, Neulasta, Procrit/Epogen — step edits suspended until shortage resolved for Procrit/Epogen — Eylea, Lucentis, and codes like J9035, J2505, J0885, J0179, C9399).

Defined Terms

Definitions

Step therapyA utilization management program that requires trying preferred (typically lower-cost) alternatives before a non-preferred drug will be covered.

Preferred productMedications identified by Florida Blue as lower-cost or preferred alternatives within a therapeutic class; may still require pre-authorization.

Non-preferred productHigher-cost medications for which step therapy is required; coverage contingent on meeting step therapy and medical necessity criteria.