Medical Drug and Step Therapy Prior Authorization List for ...

1 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 1 This document lists the Medical benefit drugs that have Authorization or step Therapy requirements for medicare advantage members. The Submit Authorization request through columns in this table specify where to submit Authorization requests for each drug: For most Medical benefit drugs, including CAR-T cell Therapy drugs, you ll submit Authorization requests through the NovoLogix online tool. For Medical oncology and supportive care drugs, you ll submit Authorization requests to AIM Specialty Health . Note: If this list specifies that you should submit an Authorization request through AIM but you re prescribing the drug for a non-oncology diagnosis, don t submit the request to AIM.

2 Instead, call the Pharmacy Clinical Help Desk at 1-800-437-3803. See the revision history at the end of this document for information about changes to this list. HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM C9090 Plasminogen, human-tvmh Ryplazim 1/17/2022 1/17/2022 C9093 Ranibizumab injection, for ocular implant Susvimo 12/27/2021 12/27/2021 G2082 Esketamine Spravato (up to 56 mg plus observation) 2020 2020 G2083 Esketamine Spravato (greater than 56 mg plus observation) 2020 2020 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 2 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J0129 Abatacept Orencia Try/fail Inflectra or Avsola (after 4/1/2022) Prior to 4/1/2022 Inflectra or Renflexis These preferred drugs don t require Authorization .

3 2017 2018 J0172 Aducanumab-avwa Aduhelm 6/8/2021 6/8/2021 J0178 Aflibercept Eylea 2017 2017 J0179 Brolucizumab-dbll Beovu 2020 2020 J0180 Agalsidase beta Fabrazyme 2017 2017 J0219 Avalglucosidase alfa-ngpt Nexviazyme 9/1/2021 9/1/2021 J0221 Alglucosidase alfa, 10mg Lumizyme 2017 2017 J0222 Patisiran Onpattro 2019 2019 J0223 Givosiran Givlaari 2020 2020 J0224 Lumasiran Oxlumo 6/22/2021 6/22/2021 J0256 Alpha 1-proteinase inhibitor (human), NOS, 10mg Aralast NP , Prolastin C , Zemaira 2017 2017 J0257 Alpha 1-proteinase inhibitor (human), 10mg Glassia 2017 2017 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 3 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J0490 Belimumab Benlysta 2017 2018 J0491 Anifrolumab-fnia Saphnelo 9/1/2021 9/1/2021 J0517 Benralizumab Fasenra 2018 2018 J0565 Bezlotoxumab Zinplava 2019 2019 J0584 Burosumab-twza Crysvita 2019 2019 J0585 Injection, onabotulinumtoxin A Botox 2017 2017 J0586 Injection.

4 Abobotulinumtoxin A Dysport 2017 2017 J0587 Injection, rimabotulinumtoxin B Myobloc 2017 2017 J0588 Injection, incobotulinumtoxin A Xeomin 2017 2017 J0638 Canakinumab Ilaris 2020 2020 J0641 Levoleucovorin Fusilev 2020 2020 J0642 Levoleucovorin Khapzory 2020 2020 J0717 Certolizumab pegol Cimzia 2017 2018 J0775 Collagenase clostridium histolyticum Xiaflex 2017 2017 J0791 Crizanlizumab Adakveo 2020 2020 J0896 Luspatercept-aamt Reblozyl 2020 2020 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 4 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J0897 Denosumab Prolia 2017 2017 J0897 Denosumab Xgeva 2020 2017 J1300 Eculizumab Soliris 2017 2018 J1301 Edaravone Radicava 2019 2019 J1303 Ravulizumab-cwvz Ultomiris 2019 2019 J1305 Evinacumab-dgnb Evkeeza 6/22/2021 6/22/2021 J1322 Elosulfase alfa Vimizim 2017 2017 J1325 Epoprostenol Flolan.

5 Veletri 2017 2017 J1427 Viltolarsen Viltepso 1/1/2021 1/1/2021 J1428 Eteplirsen Exondys 51 2020 2020 J1429 Golodirsen Vyondys 53 2020 2020 J1442 Filgrastim Neupogen Use the following preferred filgrastim biosimilar drugs first: Nivestym or Zarxio. Submit Authorization requests for these preferred drugs to AIM. 2020 2020 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 5 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J1447 Tbo-filgrastim Granix Use the following preferred filgrastim biosimilar drugs first: Nivestym or Zarxio.

6 Submit Authorization requests for these preferred drugs to AIM. 2020 2020 J1448 Trilaciclib Cosela 5/24/2021 5/24/2021 J1458 Galsulfase Naglazyme 2017 2017 J1459 Immune globulin IV (human), 10% liquid Privigen 2017 2018 J1460 Immune globulin (human), IM GamaSTAN , GamaSTAN S/D 2017 2018 J1554 Immune globulin Intravenous (human) slra 10% Asceniv 2019 2019 J1555 Immune globulin Subcutaneous (Human) 20% Cuvitru 2020 2020 J1556 Immune globulin Intravenous (human), 10% Bivigam 2017 2017 J1557 Immune globulin Intravenous (human) Gammaplex 2017 2017 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 6 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J1558 Immune globulin subcutaneous (human)-klhw Xembify 2020 2020 J1559 Immune globulin Subcutaneous (human), 20% Hizentra 2017 2017 J1560 Immune globulin (human), IM (Over 10 mL) GamaSTAN , GamaSTAN S/D 2017 2018 J1561 Immune globulin Injection (human)

7 , 10% Gamunex-C , Gammaked 2017 2017 J1566 Immune globulin Intravenous (human) Carimune NF, Gammagard S/D Less IgA 2017 2017 J1568 Immune globulin Intravenous (human) Octagam 2017 2017 J1569 Immune globulin Infusion (human) 10% Gammagard Liquid 2017 2017 J1575 Immune globulin Infusion 10% (human) with recombinant human hyaluronidase Hyqvia 2017 2017 J1599 Immune globulin subcutaneous (human)-hipp Cutaquig 2020 2020 J1599 Immune globulin Intravenous (human) ifas 10% Panzyga 2020 2020 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 7 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J1602 Golimumab Simponi Aria 2017 2018 J1743 Idursulfase Elaprase 2017 2017 J1745 Infliximab Remicade Try/fail Inflectra or Avsola (after 4/1/2022) Prior to 4/1/2022 Inflectra or Renflexis These preferred drugs don t require Authorization .

8 2017 2017 J1746 Ibalizumab-uiyk Trogarzo 2019 2019 J1786 Imiglucerase Cerezyme 2017 2017 J1823 Inebilizumab-cdon Uplizna 2020 2020 J1931 Laronidase Aldurazyme 2017 2017 J2182 Mepolizumab Nucala 2018 2017 J2326 Nusinersen Spinraza 2018 2018 J2357 Omalizumab Xolair 2018 2018 J2503 Pegaptanib Macugen 2017 2017 J2506 Pegfilgrastim Neulasta 2020 2020 J2507 Pegloticase Krystexxa 2017 2018 J2562 Plerixafor Mozobil 2020 2020 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 8 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J2778 Ranibizumab Lucentis 2017 2017 J2786 Reslizumab Cinqair 2018 2017 J2793 Rilonacept Arcalyst 9/13/2021 9/13/2021 J2796 Romiplostim Nplate 2017 2018 J2820 Sargramostim Prokine , Leukine 2020 2020 J2840 Sebelipase alfa Kanuma 2019 2017 J2860 Siltuximab Sylvant 2019 2019 J3032 Eptinezumab-jjmr Vyepti Try/fail botulinum toxins AND CGRP antagonists.

9 2020 2020 J3060 Taliglucerase alfa Elelyso 2017 2017 J3111 Romosozumab-aqqg Evenity 2019 2019 J3241 Teprotumumab Tepezza 2020 2020 J3245 Tildrakizumab-asmn Ilumya Try/fail Inflectra or Avsola (after 4/1/2022) Prior to 4/1/2022 Inflectra or Renflexis These preferred drugs don t require Authorization . 2019 2019 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 9 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare Plus Blue BCN advantage NovoLogix AIM J3262 Tocilizumab Actemra Try/fail Inflectra or Avsola (after 4/1/2022) Prior to 4/1/2022 Inflectra or Renflexis These preferred drugs don t require Authorization .

10 2017 2017 J3285 Treprostinil Remodulin 2017 2017 J3304 Triamcinolone-acetonide extended release Zilretta 2019 2019 J3357 Ustekinumab Stelara SQ Try/fail Inflectra or Avsola (after 4/1/2022) Prior to 4/1/2022 Inflectra or Renflexis These preferred drugs don t require Authorization . 2019 2019 Medical Drug and Step Therapy Prior Authorization List for medicare Plus BlueSM and BCN AdvantageSM members Revised March 9, 2022 10 HCPCS codes Generic name Trade name Step Therapy requirement Prior Authorization requirement effective date Submit Authorization request through medicare