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Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

1 In this document Drugs that require prior authorization ..................................................................................................................................................................... 2 Revision history .................................................................................................................................................................................................... 53

This document lists the medical benefit drugs that have prior authorization or step therapy requirements for Medicare Advantage members. Here’s what these terms mean: • Prior authorization – For the drugs listed in this document, approval is needed from the plan before the plan will cover the drug. This requirement helps ensure medication safety and helps guide the appropriate use of certain drugs. • Step therapy – For certain drugs, members must first try another drug to treat a medical condition before the plan will cover the drug. Refer to the “Step therapy requirement” column to see whether a drug has a step therapy requirement. For provider use The “Submit authorization request through” columns in this table specify where to submit prior authorization requests for each drug: • For most medical benefit drugs, including the CAR-T cell therapy drugs Abecma®, Breyanzi®, Carvykti™, Kymriah®, Tecartus®, Yescarta® and Aucatzyl®, submit prior authorization requests through the Medical and Pharmacy Drug PA Portal. • For medical oncology and supportive care drugs, submit prior authorization requests to OncoHealth. For additional information, see the document Oncology Value Management program through OncoHealth: Frequently asked questions for providers. Note: If this list specifies that you should submit a prior authorization request to OncoHealth but you’re prescribing the drug for a non-oncology diagnosis, don’t submit the request to OncoHealth. Instead, call the Pharmacy Clinical Help Desk at 1-800-437-3803. To view our medical policies for medical benefit drugs, see the For Providers: How Do I Submit a Drug Prior Authorization Request for Medicare Plus Blue PPO and BCN Advantage? page of our bcbsm.com/providers website.
See the revision history at the end of this document for information about changes to this list.

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Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

2 Drugs that require prior authorization HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J0129 Abatacept Orencia® ✓ Trial and failure of Inflectra® or Avsola®. AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Trial and failure of adalimumab and Orencia SC is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Trial and failure of Steqeyma®, Pyzchiva® or Wezlana® is NOT required for rheumatoid arthritis. Note: Orencia SC is not required for aGVHD 2017 2018 ✓

J0174 Lecanemab-irmb Leqembi®

2023 2023 ✓

J0175 Donanemab-azbt Kisunla™

2024 2024 ✓

J0177 Aflibercept Eylea® HD ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 2023 2023 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

3 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J0178 Aflibercept Eylea®
✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 2017 2017 ✓

J0179 Brolucizumab-dbll Beovu® ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 2020 2020 ✓

J0180 Agalsidase beta Fabrazyme®

2017 2017 ✓

J0185 Aprepitant Cinvanti® ✓ 1/1/2026 1/1/2026

✓ J0217 Velmanase alfa Lamzede®

2023 2023 ✓

J0218 Olipudase alfa-rpcp Xenpozyme®

2022 2022 ✓

J0219 Avalglucosidase alfa- ngpt Nexviazyme®

2021 2021 ✓

J0221 Alglucosidase alfa, 10mg Lumizyme®

2017 2017 ✓

J0222 Patisiran Onpattro®

2019 2019 ✓

J0223 Givosiran Givlaari®

2020 2020 ✓

J0224 Lumasiran Oxlumo®

2021 2021 ✓

J0225 Vutrisiran Amvuttra® ✓ 2022 2022 ✓

J0490 Belimumab Benlysta® ✓ Trial and failure of subcutaneous Benlysta® 2017 2018 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

4 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J0491 Anifrolumab-fnia Saphnelo® ✓ Trial and failure of Benlysta 2021 2021 ✓

J0517 Benralizumab Fasenra® ✓ 2018 2018 ✓

J0565 Bezlotoxumab Zinplava®

2019 2019 ✓

J0584 Burosumab-twza Crysvita® ✓ 2019 2019 ✓

J0586 Injection, abobotulinumtoxin A Dysport® ✓ Trial and failure of Botox® and Xeomin® These preferred drugs don’t require prior authorization. Note: Step therapy with Xeomin won’t be required for chronic migraines or urinary conditions. 2017 2017 ✓

J0587 Injection, rimabotulinumtoxin B Myobloc® ✓ Trial and failure of Botox® and Xeomin® These preferred drugs don’t require prior authorization. Note: Step therapy with Xeomin won’t be required for chronic migraines or urinary conditions. 2017 2017 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

5 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J0589 Daxibotulinumtoxin A Daxxify® ✓ Trial and failure of Botox® and Xeomin® These preferred drugs don’t require prior authorization. Note: Step therapy with Xeomin won’t be required for chronic migraines or urinary conditions. 2023 2023 ✓

J0638 Canakinumab Ilaris® ✓ 2020 2020 ✓

J0642 Levoleucovorin Khapzory®

2020 2020

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

6 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J0717 Certolizumab pegol Cimzia® ✓ Trial and failure of Inflectra® or Avsola®. AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Trial and failure of Steqeyma, Pyzchiva or Wezlana is NOT required for rheumatoid arthritis or ankylosing spondylitis. 2017 2018 ✓

J0791 Crizanlizumab Adakveo® ✓ 2020 2020 ✓

J0870 Imetalast Rytelo™ ✓ 2024 2024

✓ J0896 Luspatercept-aamt Reblozyl® ✓ 2020 2020

✓ J0897 Denosumab Prolia®
✓ Use the preferred denosumab biosimilar Stoboclo® 2017 2017 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

7 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J0897 Denosumab Xgeva® ✓ Use the preferred denosumab biosimilar Osenvelt® The preferred drug doesn’t require prior authorization. 12/1/2025 12/1/2025 ✓

J1203 Cipaglucosidase alfa- atga Pombiliti®

2024 2024 ✓

J1299 Eculizumab Soliris® ✓ For myasthenia gravis: Trial and failure of Truxima, Ruxience or Riabni, Vyvgart or Vyvgart Hytrulo, Rystiggo AND Epysqli is required. For NMOSD: Trial and failure of Enspryng® and Uplizna® For PNH: Trial and failure of Empaveli® and Epysqli 2017 2018 ✓

J1301 Edaravone Radicava®

2019 2019 ✓

J1302 Sutimilab-jome Enjaymo® ✓ 2022 2022 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

8 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1303 Ravulizumab-cwvz Ultomiris® ✓ For myasthenia gravis: Trial and failure of Truxima, Ruxience or Riabni, Vyvgart or Vyvgart Hytrulo, Rystiggo AND Epysqli is required.
For NMOSD: Trial and failure of Enspryng® and Uplizna® For PNH: Trial and failure of Empaveli® and Epysqli For aHUS: Trial and failure of Epysqli 2019 2019 ✓

J1304 Tofersen Qalsody®

2023 2023 ✓

J1305 Evinacumab-dgnb Evkeeza® ✓ Trial and failure of a high-intensity statin AND Praluent® or Repatha® 2021 2021 ✓

J1306 Inclisiran Leqvio® ✓ Trial and failure of a high-intensity statin AND Praluent® or Repatha® 2022 2022 ✓

J1307 Crovalimab-akkz PiaSky® ✓ 2024 2024 ✓

J1322 Elosulfase alfa Vimizim®

2017 2017 ✓

J1323 Elranatamab-bcmm Elrexfio®

2024 2024

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

9 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1325 Epoprostenol Flolan®,
Veletri®

2017 2017 ✓

J1326 Zolbetuximab-clzb Vyloy®

8/20/2025 8/20/2025

✓ J1411 Etranacogene dezaparvovec-drlb Hemgenix®

2022 2022 ✓

J1412 Valoctocogene roxaparvovec-rvox Roctavian® ✓ 2023 2023 ✓

J1413 Delandistrogene moxeparvovec-rokl Elevidys

2023 2023 ✓

J1427 Viltolarsen Viltepso®

2021 2021 ✓

J1428 Eteplirsen Exondys 51®

2020 2020 ✓

J1429 Golodirsen Vyondys 53®

2020 2020 ✓

J1434 Fosaprepitant Focinvez™ ✓ 1/1/2026 1/1/2026

✓ J1437 Ferric derisomaltose Monoferric® ✓ Trial and failure of at least TWO of the following preferred medications: Ferrlecit®, Feraheme®, Venofer® or INFeD® These preferred drugs don’t require prior authorization. 2022 2022 ✓

Prior authorization isn’t required when these medications are received through a dialysis facility.

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

10 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1439 Ferric carboxymaltose Injectafer® ✓ Trial and failure of at least TWO of the following preferred medications first: Ferrlecit®, Feraheme®, Venofer® or INFeD®. These preferred drugs don’t require prior authorization. 2022 2022 ✓

Prior authorization isn’t required when these medications are received through a dialysis facility. J1440 Fecal microbiota, live- jslm Rebyota®

2023 2023 ✓

J1442 Filgrastim Neupogen® ✓ Use both of the following preferred filgrastim biosimilar drugs: Nivestym® AND Zarxio® 2020 2020

✓ J1447 Tbo-filgrastim* Granix® ✓ Use both of the following preferred filgrastim biosimilar drugs: Nivestym® AND Zarxio®
2020 2020

✓ J1448 Trilaciclib
Cosela®

2021 2021

✓ J1449 Eflapegrastim-xnst Rolvedon® ✓ Use all of the following preferred pegfilgrastim drugs: Fulphila®, AND Neulasta® or Neulasta OnPro 2023 2023

✓
J1454 Netupitant/ palonosetron Akynzeo® ✓ 1/1/2026 1/1/2026

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

11 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1458 Galsulfase Naglazyme®

2017 2017 ✓

J1459 Immune globulin IV (human), 10% liquid Privigen® ✓ Trial and failure of Gammagard® and Octagam® 2017 2018 ✓

J1460 Immune globulin (human), IM GamaSTAN®, GamaSTAN S/D® ✓

2017 2018 ✓

J1551 Immune globulin subcutaneous (human)-hipp Cutaquig® ✓ Trial and failure of Gammagard® or Octagam® AND Hizentra® 2020 2020 ✓

J1552 Immune globulin intravenous, human- stwk 10% Alyglo™ ✓ Trial and failure of Gammagard® and Octagam® 2024 2024 ✓

J1553 immune globulin intravenous, human- dira Yimmugo® ✓ Trial and failure of Gammagard® and Octagam® 10/27/2025 10/27/2025 ✓

J1554 Immune globulin Intravenous (human) slra 10% Asceniv® ✓ Trial and failure of Gammagard® and Octagam® 2019 2019 ✓

J1555 Immune globulin Subcutaneous (Human) 20% Cuvitru® ✓ Trial and failure of Gammagard or Octagam® AND Hizentra® 2020 2020 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

12 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1556 Immune globulin Intravenous (human), 10% Bivigam® ✓ Trial and failure of Gammagard® and Octagam® 2017 2017 ✓

J1557 Immune globulin Intravenous (human) Gammaplex® ✓ Trial and failure of Gammagard® and Octagam® 2017 2017 ✓

J1558 Immune globulin subcutaneous (human)-klhw Xembify® ✓ Trial and failure of Gammagard® or Octagam® AND Hizentra® 2020 2020 ✓

J1559 Immune globulin Subcutaneous (human), 20% Hizentra® ✓ Trial and failure of Gammagard® or Octagam® Note: Gammagard® or Octagam® is not required for CIDP 2017 2017 ✓

J1560 Immune globulin (human), IM (Over 10 mL) GamaSTAN®, GamaSTAN S/D® ✓ 2017 2018 ✓

J1561 Immune globulin Injection (human), 10% Gamunex-C®,
Gammaked™ ✓ Trial and failure of Gammagard® and Octagam® 2017 2017 ✓

J1566 Immune globulin Intravenous (human) Gammagard S/D® Less IgA ✓ Trial and failure of Gammagard® and Octagam® 2017 2017 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

13 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1568 Immune globulin Intravenous (human) Octagam® ✓ 2017 2017 ✓

J1569 Immune globulin Infusion (human) 10% Gammagard® Liquid ✓ 2017 2017 ✓

J1569 Immune globulin Infusion (human) 10% Gammagard Liquid® ERC ✓ Trial and failure of Gammagard® and Octagam® 5/11/2026 5/11/2026 ✓

J1572 Immune globulin Intravenous (human) Flebogamma® DIF ✓ Trial and failure of Gammagard® and Octagam® 2024 2024 ✓

J1575 Immune globulin Infusion 10% (human) with recombinant human hyaluronidase Hyqvia® ✓ Trial and failure of Gammagard® or Octagam® AND Hizentra® 2017 2017 ✓

J1576 Immune globulin Intravenous (human) – ifas 10% Panzyga® ✓ Trial and failure of Gammagard® and Octagam® 2020 2020 ✓

J1599 Immune globulin Intravenous (human) Qivigy® ✓ Trial and failure of Gammagard® and Octagam® 6/22/2026 6/22/2026

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

14 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1602 Golimumab Simponi Aria® ✓ Trial and failure of Inflectra® or Avsola®. AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Trial and failure of Steqeyma, Pyzchiva or Wezlana is NOT required for rheumatoid arthritis or ankylosing spondylitis. 2017 2018 ✓

J1627 Granisetron Sustol® ✓ 1/1/2026 1/1/2026

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

15 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1628 Guselkumab Tremfya® IV ✓ Trial and failure of Inflectra® or Avsola®. AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). 2024 2024 ✓

J1743 Idursulfase Elaprase®

2017 2017 ✓

J1745 Infliximab Remicade® ✓ Trial and failure of Inflectra® AND Avsola® These preferred drugs don’t require authorization. 2017 2017 ✓

J1745 Infliximab Generic (non- biosimilar) ✓ Trial and failure of Inflectra® AND Avsola® These preferred drugs don’t require authorization. 2023 2023 ✓

J1746 Ibalizumab-uiyk Trogarzo® ✓ 2019 2019 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

16 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J1747 Spesolimab-sbzo Spevigo® ✓ 2022 2022 ✓

J1747 Spesolimab-sbzo Spevigo® SC ✓ 2024 2024 ✓

J1809 Fosdenopterin Nulibry®

2021 2021 ✓

J1823 Inebilizumab-cdon Uplizna® ✓ 2020 2020 ✓

J1931 Laronidase Aldurazyme®

2017 2017 ✓

J2182 Mepolizumab Nucala® ✓ 2018 2017 ✓

J2267 Mirikizumab-mrkz Omvoh® IV ✓ Trial and failure of Inflectra® or Avsola®. AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). 2024 2024 ✓

J2323 Natalizumab Tysabri® ✓ Trial and failure of dimethyl fumarate, glatiramer, fingolimod and Ocrevus. 6/22/2026 6/22/2026 ✓

J2326 Nusinersen Spinraza®

2018 2018 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

17 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J2327 Risankizumab-rzaa Skyrizi® IV
✓ Trial and failure of Inflectra® or Avsola®. AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). 2022 2022 ✓

J2329 Ublituximab-xiiy Briumvi® ✓ Trial and failure of dimethyl fumarate, glatiramer, fingolimod, Ocrevus and Tysabri or Tyruko. 6/22/2026 6/22/2026 ✓

J2350 Ocrelizumab Ocrevus® ✓ Trial and failure of dimethyl fumarate, glatiramer and fingolimod.
Note: Step therapy does not apply for diagnosis of primary progressive multiple sclerosis 6/22/2026 6/22/2026 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

18 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J2351 Ocrelizumab and hyaluronidase-ocsq Ocrevus Zunovo® ✓ Trial and failure of dimethyl fumarate, glatiramer and fingolimod AND Ocrevus. Note: Trial and failure of dimethyl fumarate, glatiramer and fingolimod is not required for diagnosis of primary progressive multiple sclerosis.
6/22/2026 6/22/2026 ✓

J2356 Tezepelumab-ekko Tezspire® ✓ For eosinophilic asthma: Trial and failure of Fasenra® or Nucala® AND Dupixent®
For allergic asthma: Trial and failure of Xolair® For oral steroid dependent asthma: Trial and failure of Dupixent® 2022 2022 ✓

J2357 Omalizumab Xolair® ✓ 2018 2018 ✓

J2506 Pegfilgrastim Neulasta® Neulasta® Onpro®

2020 2020

✓ J2507 Pegloticase Krystexxa® ✓ 2017 2018 ✓

J2508 Pegunigalsidase alfa- iwxj Elfabrio®

2023 2023 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

19 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J2777 Faricimab-svoa Vabysmo® ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar Trial and failure of aflibercept, ranibizumab, or Beovu® is also required. 2022 2022 ✓

J2778 Ranibizumab Lucentis® ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 2017 2017 ✓

J2779 Ranibizumab injection, for ocular implant Susvimo® ✓ 2021 2021 ✓

J2781 Pegcetacoplan injection Syfovre®

2023 2023 ✓

J2782 Avacincaptad pegol Izervay™ ✓ Trial and failure of Syfovre® 2023 2023 ✓

J2786 Reslizumab Cinqair® ✓ Trial and failure of Fasenra® or Nucala® AND Dupixent® 2018 2017 ✓

J2793 Rilonacept Arcalyst® ✓ 2021 2021 ✓

J2802 Romiplostim Nplate® ✓ 2017 2018 ✓

J2820 Sargramostim Prokine®, Leukine®

2020 2020

✓ J2840 Sebelipase alfa Kanuma®

2019 2017 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

20 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J2998 Plasminogen, human- tvmh Ryplazim®

2022 2022 ✓

J3032 Eptinezumab-jjmr Vyepti® ✓ Trial and failure of botulinum toxins AND an oral or subcutaneous CGRP antagonist 2020 2020 ✓

J3055 Talquetamab-tgvs Talvey®

2024 2024

✓ J3060 Taliglucerase alfa Elelyso® ✓ Trial and failure of Cerezyme® This preferred drug doesn’t require prior authorization. 2017 2017 ✓

J3111 Romosozumab-aqqg Evenity® ✓ For high-risk osteoporosis: Trial and failure of oral or IV bisphosphonates AND a denosumab product
For very high-risk osteoporosis: Trial and failure of zoledronate only or a denosumab product only if zoledronate is contraindicated 2019 2019 ✓

J3241 Teprotumumab Tepezza® ✓ 2020 2020 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

21 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J3245 Tildrakizumab-asmn Ilumya® ✓ Trial and failure of Inflectra® or Avsola® AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). 2019 2019 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

22 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J3247 Secukinumab Cosentyx® IV ✓ Trial and failure of Inflectra® or Avsola® AND Steqeyma®, Pyzchiva® or Wezlana®
These preferred drugs don’t require prior authorization. Note: Trial and failure of Steqeyma, Pyzchiva or Wezlana is NOT required for ankylosing spondylitis. Trial and failure of adalimumab and Cosentyx SC is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). 2024 2024 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

23 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J3262 Tocilizumab Actemra® ✓ Trial and failure of Tyenne AND Inflectra® or Avsola® These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Infliximab and adalimumab are NOT required for cytokine release syndrome or giant cell arteritis. 2017 2017 ✓

J3263 Toripalimab-tpzi Loqtorzi®

2024 2024

✓ J3285 Treprostinil Remodulin®

2017 2017 ✓

J3304 Triamcinolone- acetonide extended release Zilretta® ✓ 2019 2019 ✓

J3358 Ustekinumab Stelara® IV ✓ Trial and failure of the following preferred ustekinumab drugs: Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 1/22/2026 1/22/2026 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

24 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J3380 Vedolizumab Entyvio® ✓ Trial and failure of Inflectra® or Avsola® AND Steqeyma, Pyzchiva, or Wezlana These preferred drugs don’t require prior authorization. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). 2017 2018 ✓

J3385 Velaglucerase alfa VPRIV® ✓ Trial and failure of Cerezyme® This preferred drug doesn’t require prior authorization. 2017 2017 ✓

J3389 Prademagene zamikeracel Zevaskyn™

7/1/2025 7/1/2025 ✓

J3392 Exagamglogene autotemcel Casgevy® ✓ 2024 2024 ✓

J3393 Betibeglogene autotemcel Zynteglo®

2022 2022 ✓

J3394 Lovotibeglogene autotemcel Lyfgenia™ ✓ 2024 2024 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

25 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J3397 Vestronidase alfa-vjbk Mepsevii®

2019 2019 ✓

J3398 Voretigene neparvovec-rzyl Luxturna®

2018 2018 ✓

J3399 Onasemnogene abeparvovec-xioi Zolgensma®

2020 2020 ✓

J3401 Beremagene geperpavec-svdt Vyjuvek®

2023 2023 ✓

J3402 Remestemcel-L-rknd Ryoncil® ✓ 2025 2025 ✓

J3403 Revakinagene taroretcel-lwey Encelto™

6/1/2025 6/1/2025 ✓

J3404 Zopapogene imadenovec-drba Papzimeos™

5/11/2026 5/11/2026 ✓

J3490 Eplontersen Wainua®

2024 2024 ✓

J3490, J3590 Pegcetacoplan Empaveli®

2021 2021 ✓

J3490 Nedosiran Rivfloza®

2024 2024 ✓

J3590 Bevacizumab-tnjn Avzivi® ✓ Use both of the following preferred bevacizumab biosimilar drugs: Zirabev® and Mvasi®.
2024 2024 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

26 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J3590 Bimekizumab-bkzx Bimzelx® ✓ Trial and failure of Inflectra® or Avsola® AND Steqeyma, Pyzchiva or Wezlana
These preferred drugs don’t require prior authorization. Note: Trial and failure of Steqeyma, Pyzchiva or Wezlana is NOT required for ankylosing spondylitis. Trial and failure of adalimumab is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). 2024 2024 ✓

J3590 Depemokimab-ulaa Exdensur ✓ 2/2/2026 2/2/2026 ✓

J3590 Denosumab-qbde Enoby™ ✓ Use the preferred denosumab biosimilar Stoboclo® 6/22/2026 6/22/2026 ✓

J3590 Denosumab-qbde Xtrenbo™ ✓ Use the preferred denosumab biosimilar Osenvelt®
The preferred drug doesn’t require prior authorization. 6/22/2026 6/22/2026 ✓

J3590 Donislecel-jujn Lantidra™

2023 2023 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

27 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J3590 Etuvetidigene autotemcel Waskyra™

1/15/2026 1/15/2026 ✓

J3590 Eladocagene exuparvovec-tneq Kebilidi™

2/3/2025 2/3/2025 ✓

J3590 Lecanemab-irmb Leqembi® IQLIK™

10/1/2025 10/1/2025 ✓

J3590 Lifileucel Amtagvi®

2024 2024 ✓

J3590 Marnetegragene autotemcel Kresladi ™

5/1/2026 5/1/2026 ✓

J3590 Narsoplimab Yartemlea™

2/2/2026 2/2/2026 ✓

J3590, C9399 Omidubicel-onlv Omisirge®

2024 2024 ✓

J3590 Onasemnogene abeparvovec-brve Itvisma®

1/15/2026 1/15/2026 ✓

J3590 Pegzilarginase-nbln Loargys®

4/1/2026 4/1/2026 ✓

J3590 Sotatercept-csrk Winrevair™ ✓ 2024 2024 ✓

J3590 Tividenofusp alfa-eknm Avlayah™

5/1/2026 5/1/2026 ✓

J3590 Ustekinumab-hmny Starjemza® IV ✓ Trial and failure of the following preferred ustekinumab drugs:
Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 5/11/2026 5/11/2026 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

28 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J7170 Emicizumab-kxwh
Hemlibra®

2020 2020 ✓

J7171 ADAMTS13, recombinant-krhn Adzynma®

2024 2024 ✓

J7172 Marstacimab-hncq Hympavzi™ ✓ 2025 2025 ✓

J7174 Fitusiran Qfitlia®

6/1/2025 6/1/2025 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

29 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J7320 Sodium hyaluronate GenVisc® 850 ✓ Trial and failure of all the following preferred hyaluronic acid drugs: Durolane®, Euflexxa®, Gelsyn-3® AND Supartz FX®. These preferred drugs don’t require authorization. 2020 2020 ✓

J7321 Sodium hyaluronate Visco-3™ Hyalgan® 2020 2020 ✓

J7322 High Molecular Weight Viscoelastic Hyaluronan Hymovis® 2020 2020 ✓

J7324 High Molecular Weight Hyaluronan Orthovisc® 2020 2020 ✓

J7325 Hylan G-F 20 Synvisc®, Synvisc-One® 2020 2020 ✓

J7326 Sodium hyaluronate Gel-one® 2020 2020 ✓

J7327 High Molecular Weight Hyaluronan Monovisc® 2020 2020 ✓

J7329 Sodium hyaluronate TriVisc® 2020 2020 ✓

J7331 Sodium hyaluronate Synojoynt® 2020 2020 ✓

J7332 Sodium hyaluronate Triluron® 2020 2020 ✓

J7352 Afamelanotide Scenesse®

2020 2020 ✓

J7601 Ensifentrine inhalation suspension Ohtuvayre® ✓ Trial and failure of Trelegy Ellipta and roflumilast 6/22/2026 6/22/2026

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

30 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J7606 Formoterol fumarate inhalation solution generic ✓ Trial and failure of arformoterol
6/22/2026 6/22/2026

✓

J7677 Revefenacin, inhalation solution Yuperli® ✓ Trial and failure of Anoro Ellipta and Stiolto® Respimat® 6/22/2026 6/22/2026

✓

J7686 Treprostinil Tyvaso® ✓ 2017 2017 ✓

Prior authorization is required for Tyvaso® nebulizer.
Note: Tyvaso DPI® (J3535) is a pharmacy benefit drug, not a medical benefit drug. J9011 Datopotamab deruxtecan-dlnk Datroway

12/1/2025 12/1/2025

✓ J9022 Atezolizumab Tecentriq®

2019 2019

✓ J9023 Avelumab Bavencio®

2019 2019

✓ J9024 Atezolizumab hyaluronidase-tqjs Tecentriq Hybreza™

6/1/2025 6/1/2025

✓ J9026 Tarlatamab-dlle Imdelltra™

6/1/2025 6/1/2025

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

31 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9028 Ogapendekin alfa inbakicept-pmln Anktiva® ✓ For use in BCG-unresponsive non- muscle invasive bladder cancer, must try and fail both Adstiladrin AND Keytruda or Keytruda Qlex 6/1/2025 6/1/2025

✓ J9029 Nadofaragene firadenovec-vncg Adstiladrin® ✓ 2023 2023 ✓

J9035 Bevacizumab Avastin® ✓ Use both of the following preferred bevacizumab biosimilar drugs: Zirabev® and Mvasi®. 2020 2020

✓ Prior authorization isn’t required for use in retinal disorders. J9038 Axatilimab-csfr Niktimvo® ✓ 2025 2025

✓ J9054 Bortezomib Boruzu® ✓ Trial and failure of generic bortezomib is required. 5/13/2026 5/13/2026

✓ J9055 Cetuximab Erbitux®

2020 2020

✓ J9056 Bendamustine Vivimusta® ✓ Trial and failure of both Belrapzo® and Bendeka® is required. These drugs don’t require prior authorization. 5/13/2026 5/13/2026

✓ J9061 Amivantamab-vmjw Rybrevant®

2021 2021

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

32 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9063 Mirvetuximab soravtansine Elahere™

2023 2023

✓ J9119 Cemiplimab-rwlc Libtayo®

2019 2019

✓ J9144 Daratumumab and hyaluronidase-fihj
Darzalex Faspro®

2020 2020

✓ J9145 Daratumumab Darzalex®

2019 2019

✓ J9161 Denileukin diftitox-cxdl Lymphir™

6/1/2025 6/1/2025

✓ J9172 Docetaxel Docivyx™ ✓ Trial and failure of Taxotere® is required. Taxotere does not require authorization. 3/4/2026 3/4/2026

✓ J9173 Durvalumab Imfinzi®

2019 2019

✓ J9174 Docetaxel Beizray® ✓ Trial and failure of Taxotere is required. Taxotere does not require authorization. 3/4/2026 3/4/2026

✓ J9176 Elotuzumab Empliciti®

2019 2019

✓ J9177 Enfortumab vedotin- ejfv Padcev®

2020 2020

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

33 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9183 Gemcitabine intravesical system Inlexzo™ ✓ For use in BCG-unresponsive non- muscle invasive bladder cancer, must
try and fail both Adstiladrin and Keytruda or Keytruda Qlex 5/13/2026 5/13/25026

✓ J9184 Gemcitabine Avgemsi™ ✓ Trial and failure of generic gemcitabine is required. 5/13/2026 5/13/25026

✓ J9204 Mogamulizumab-kpkc Poteligeo®

2020 2020

✓ J9205 Irinotecan liposome Onivyde® ✓ For use in pancreatic cancer, must first try and fail conventional irinotecan. 2020 2020

✓ J9210 Emapalumab-lzsg Gamifant® ✓ 9/3/2025 9/3/2025 ✓

J9227 Isatuximab-irfc Sarclisa®

2020 2020

✓
J9228 Ipilimumab Yervoy®

2017 2017

✓ J9256 Nipocalimab-aahu Imaavy™ ✓ Trial and failure of Truxima, Ruxience or Riabni is required
These preferred drugs don’t require authorization. 7/1/2025 7/1/2025 ✓

J9264 Paclitaxel protein- bound particles Abraxane® ✓ For use in metastatic breast cancer and non-small cell lung cancer, must first try and fail generic paclitaxel. 2020 2020

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

34 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9269 Tagraxofusp-erzs Elzonris®

2019 2019

✓ J9271 Pembrolizumab Keytruda® ✓ For use in nasopharyngeal cancer, must first try and fail Loqtorzi. 2018 2017

✓ J9272 Dostarlimab-gxly Jemperli

2021 2021

✓ J9273 Tisotumab vedotin-tftv Tivdak®

2022 2022

✓ J9274 Tebentafusp-tebn Kimmtrak®

2022 2022

✓ J9275 Cosibelimab-ipdl Unloxcyt™

8/20/2025 08/20/2025

✓ J9276 Zanidatamab-hrii Ziihera®

8/20/2025 8/20/2025

✓ J9277 Pembrolizumab and berahyaluronidase alfa-pmph Keytruda Qlex™ ✓ For use in nasopharyngeal cancer, must first try and fail Loqtorzi. 5/13/2026 5/13/2026

✓ J9278 Carboplatin Kyxata™ ✓ Trial and failure of generic carboplatin is required 5/13/2026 5/13/25026

✓ J9281 Mitomycin Jelmyto®

2020 2020

✓ J9282 Mitomycin Zusduri™

3/4/2026 3/4/2026

✓ J9286 Glofitamab-gxbm Columvi™

2024 2024

✓ J9289 Nivolumab and hyaluronidase-nvhy Opdivo Qvantig™ For use in nasopharyngeal cancer, must first try and fail Loqtorzi. 08/20/2025 08/20/2025

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

35 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9292, J9294, J9296, J9297 Pemetrexed Generic (various brands)

2023 2023

✓ J9298 Nivolumab and relatlimab-rmbw Opdualag™

2022 2022

✓ J9299 Nivolumab Opdivo® ✓ For use in nasopharyngeal cancer, must first try and fail Loqtorzi. 2018 2017

✓ J9301 Obinutuzumab Gazyva®

3/4/2026 3/4/2026

✓ J9303 Panitumumab Vectibix®

2020 2020

✓ J9304 Pemetrexed Pemfexy® ✓ Trial and failure of both of the following: Alimta® AND generic pemetrexed 2023 2023

✓ J9305 Pemetrexed Alimta®

2020 2020

✓ J9306 Pertuzumab Perjeta®

2020 2020

✓ J9309 Polatuzumab Polivy®

2020 2020

✓ J9311 Rituximab- hyaluronidase human Rituxan Hycela® ✓ Use allof the preferred rituximab biosimilar drugs: Truxima®, Riabni® AND Ruxience®.
These preferred drugs don’t require authorization. 2020 2020

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

36 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9312 Rituximab Rituxan® ✓ Use all of the following preferred rituximab biosimilar drugs: Truxima, Riabni® AND Ruxience®.
These preferred drugs don’t require authorization. 2021 2021 ✓

J9314 Pemetrexed
Generic

2023 2023

✓ J9316 Pertuzumab/trastuzum ab/hyaluronidase-zzxf Phesgo®

2020 2020

✓
J9317 Sacituzumab govitecan-hziy Trodelvy®

2020 2020

✓ J9321 Epcoritamab-bysp Epkinly®

2024 2024

✓ J9322, J9323 Pemetrexed
Generic (various brands)

2023 2023

✓ J9324 Pemetrexed
Pemrydi® RTU ✓ Trial and failure of both of the following: Alimta® and generic pemetrexed 2024 2024

✓ J9326 Telisotuzumab vedotin- tllv Emrelis™

3/4/2026 3/4/2026

✓ J9329 Tislelizumab-jsgr Tevimbra®

2025 2025

✓ J9331 Sirolimus albumin- bound Fyarro®

2022 2022

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

37 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9332 Efgartigimod alfa-fcab Vyvgart® ✓ For myasthenia gravis: Trial and failure of Truxima, Ruxience or Riabni is required. These preferred drugs don’t require authorization. 2022 2022 ✓

J9333 Rozanolixizumab-noli Rystiggo® ✓ Trial and failure of Truxima, Ruxience or Riabni is required
These preferred drugs don’t require authorization. 2023 2023 ✓

J9334 Efgartigimod alfa and hyaluronidase-qvfc Vyvgart® Hytrulo ✓ For myasthenia gravis: Trial and failure of Truxima, Ruxience or Riabni is required.
These preferred drugs don’t require authorization. For CIDP: Trial and failure of Gammagard or Octagam is required. 2023 2023 ✓

J9345 Retifanlimab-dlwr Zynyz®

2023 2023

✓ J9347 Tremelimumab-actl Imjudo®

2023 2023

✓ J9348 Naxitamab-gqgk
Danyelza®

2021 2021

✓ J9349 Tafasitamab-cxix Monjuvi®

2020 2020

✓ J9350 Mosunetuzumab-axgb Lunsumio™ IV

2023 2023

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

38 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9350 Mosunetuzumab-axgb Lunsumio VELO™

4/1/2026 4/1/2026

✓ J9352 Trabectedin Yondelis®

2019 2019

✓ J9353 Margetuximab-cmkb Margenza®

2021 2021

✓ J9354 Ado-trastuzumab emtansine Kadcyla®

2020 2020

✓ J9355 Trastuzumab Herceptin® ✓ Use both of the preferred trastuzumab biosimilars Ontruzant® and Trazimera® 2020 2020

✓ J9356 Trastuzumab and hyaluronidase-oysk Herceptin Hylecta™ ✓ Use both of the preferred trastuzumab biosimilars Ontruzant® and Trazimera® 2020 2020

✓ J9358 Fam-trastuzumab-nxki Enhertu®

2020 2020

✓ J9359 Loncastuximab tesirine-lpyl Zynlonta®

2021 2021

✓ J9361 Efbemalenograstim alfa-vuxw* Ryzneuta® ✓ Use all of the following preferred pegfilgrastim drugs: Fulphila® AND Neulasta® or Neulasta OnPro
2024 2024

✓ J9376 Pozelimab-bbfg Veopoz™ ✓ 2023 2023 ✓

J9380 Teclistamab-cqyv Tecvayli®

2023 2023

✓ J9381 Teplizumab-mzwv Tzield®

2022 2022 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

39 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth J9382 Zenocutuzumab-zbco Bizengri®

8/20/2025 8/20/2025

✓ J9601 Linvoseltamab-gcpt Lynozyfic™

5/13/2026 5/13/25026

✓ Q2041 Axicabtagene ciloleucel (CAR-T) Yescarta®

2021 2021 ✓

Q2042 Tisagenlecleucel (CAR-T) Kymriah®

2021 2021 ✓

Q2053 Brexucabtagene autoleucel (CAR-T) Tecartus®

2021 2021 ✓

Q2054 Lisocabtagene maraleucel (CAR-T) Breyanzi®

2021 2021 ✓

Q2055 Idecabtagene vicleucel (CAR-T) Abecma®

2021 2021 ✓

Q2056 Ciltacabtagene autoleucel (CAR-T) Carvykti®

2022 2022 ✓

Q2057 Afamitresgene autoleucel Tecelra® ✓ 2024 2024 ✓

Q2058 Obecabtagene autoleucel (CAR-T) Aucatzyl®

2024 2024 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

40 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5098 Ustekinumab-srlf Imuldosa® IV ✓ Use all of the following preferred ustekinumab drugs: Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 2025 2025 ✓

Q5100 Ustekinumab-kfce Yesintek™ IV ✓ Use all of the following preferred ustekinumab drugs: Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 2025 2025 ✓

Q4074 Iloprost Ventavis® ✓ 2020 2020 ✓

Q5101 Filgrastim-sndz Zarxio®

2020 2020

✓ Q5104 Infliximab-abda Renflexis® ✓ Trial and failure of Inflectra and Avsola
These preferred drugs don’t require authorization 1/1/2026 1/1/2026 ✓

Q5104 Infliximab-abda Unbranded biosimilar ✓ Trial and failure of Inflectra and Avsola These preferred drugs don’t require authorization 1/1/2026 1/1/2026 ✓

Q5107 Bevacizumab-awwb Mvasi®

2020 2020

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

41 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5108 Pegfilgrastim-jmdb Fulphila®

2020 2020

✓ Q5110 Filgrastim-aafi Nivestym®

2020 2020

✓ Q5111 Pegfilgrastim-cbqv Udenyca®

✓ Use all of the following preferred pegfilgrastim drugs: Fulphila® AND Neulasta® or Neulasta OnPro 2020 2020

✓ Q5111 Pegfilgrastim-cbqv Udenyca® Onbody ✓ Use all of the following preferred pegfilgrastim drugs: Fulphila® AND Neulasta® or Neulasta OnPro 2024 2024

✓ Q5112 Trastuzumab-dttb Ontruzant®

2020 2020

✓ Q5113 Trastuzumab-pkrb Herzuma® ✓ Use both of the preferred trastuzumab biosimilars Ontruzant® and Trazimera® 2020 2020

✓ Q5114 Trastuzumab-dkst Ogivri® ✓ Use both of the preferred trastuzumab biosimilars Ontruzant® and Trazimera® 2020 2020

✓ Q5116 Trastuzumab-qyyp Trazimera®

2020 2020

✓ Q5117 Trastuzumab-anns Kanjinti® ✓ Use both of the preferred trastuzumab biosimilars Ontruzant® and Trazimera®
2020 2020

✓ Q5118 Bevacizumab-bvzr Zirabev®

2020 2020

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

42 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5120 Pegfilgrastim-bmez Ziextenzo® ✓ Use all of the following preferred pegfilgrastim drugs: Fulphila® AND Neulasta® or Neulasta OnPro 2020 2020

✓ Q5122 Pegfilgrastim-apgf Nyvepria® ✓ Use all of the following preferred pegfilgrastim drugs: Fulphila® AND Neulasta® or Neulasta OnPro 2020 2020

✓ Q5124 Ranibizumab-nuna ByoovizTM ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 2022 2022 ✓

Q5125 Filgrastim-ayow Releuko® ✓ Use both of the following preferred filgrastim biosimilar drugs: Nivestym® AND Zarxio®. 2022 2022

✓ Q5126 Bevacizumab-maly Alymsys® ✓ Use both of the following preferred bevacizumab biosimilar drugs: Zirabev® and Mvasi®. 2022 2022

✓ Q5127 Pegfilgrastim-fpgk Stimufend® ✓ Use all of the following preferred pegfilgrastim drugs: Fulphila® AND Neulasta® or Neulasta OnPro 2023 2023

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

43 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5128 Ranibizumab_eqrn Cimerli® ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 2022 2022 ✓

Q5129 Bevacizumab-adcd Vegzelma® ✓ Use both of the following preferred bevacizumab biosimilar drugs: Zirabev® and Mvasi®.
2023 2023

✓ Q5130 Pegfilgrastim-pbbk Fylnetra® ✓ Use all of the following preferred pegfilgrastim drugs: Fulphila® AND Neulasta® or Neulasta OnPro 2022 2022

✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

44 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5133 Tocilizumab-bavi

Tofidence™ ✓ Trial and failure of Tyenne AND Trial and failure of Inflectra® or Avsola®. These preferred drugs don’t require prior authorization. Trial and failure of adalimumab and Tyenne SC is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Tyenne SC is not required for cytokine release syndrome and COVID-19 Note: Infliximab and adalimumab are not required for cytokine release syndrome or giant cell arteritis. 2024 2024 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

45 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5134 Natalizumab-sztn Tyruko® ✓ Trial and failure of dimethyl fumarate, glatiramer, fingolimod AND Ocrevus 6/22/2026 6/22/2026 ✓

Q5135 Tocilizumab-aazg Tyenne® ✓ Trial and failure of Inflectra® or Avsola® These preferred drugs don’t require prior authorization. Trial and failure of adalimumab and Tyenne SC is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Tyenne SC is not required for treatment of cytokine release syndrome and COVID-19. Note: Infliximab and adalimumab are not required for cytokine release syndrome or giant cell arteritis. 2024 2024 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

46 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5135 Tocilizumab-aazg Unbranded biosimilar ✓ Trial and failure of Tyenne AND Trial and failure of Inflectra® or Avsola® These preferred drugs don’t require prior authorization. Trial and failure of adalimumab and Tyenne SC is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Tyenne SC is not required for treatment of cytokine release syndrome and COVID-19 Note: Infliximab and adalimumab are not required for cytokine release syndrome or giant cell arteritis. 7/1/2025 7/1/2025 ✓

Q5136 Denosumab-bbdz Jubbonti® ✓ Use the preferred denosumab biosimilar Stoboclo® 2024 2024 ✓

Q5136 Denosumab-bbdz Unbranded biosimilar ✓ Use the preferred denosumab biosimilar Stoboclo® 1/1/2026 1/1/2026 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

47 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5136 Denosumab-bbdz Wyost® ✓ Use the preferred denosumab biosimilar Osenvelt® The preferred drug doesn’t require prior authorization. 12/1/2025 12/1/2025 ✓

Q5146 Trastuzumab-strf Hercessi™ ✓
Use the preferred trastuzumab biosimilars Ontruzant® AND Trazimera®
6/1/2025 6/1/2025

✓ Q5147 Aflibercept-ayyh Pavblu™ ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 5/1/2025 5/1/2025 ✓

Q5148 Filgrastim-txid Nypozi™ ✓ Use both of the following preferred filgrastim biosimilar drugs: Nivestym® AND Zarxio®. 6/1/2025 6/1/2025

✓ Q5149 Aflibercept-abzv Enzeevu™
✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 5/1/2025 5/1/2025 ✓

Q5150 Aflibercept-mrbb Ahzantive® ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 5/1/2025 5/1/2025 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

48 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5151 Eculizumab-aagh Epysqli® ✓ For myasthenia gravis: Trial and failure of Truxima, Ruxience or Riabni, Vyvgart or Vyvgart Hytrulo AND Rystiggo is required.
For NMOSD: Trial and failure of Enspryng® and Uplizna® For PNH: Trial and failure of Empaveli® 5/1/2025 5/1/2025 ✓

Q5152 Eculizumab-aeeb Bkemv™ ✓ For myasthenia gravis: Trial and failure of Truxima, Ruxience or Riabni, Vyvgart or Vyvgart Hytrulo, Rystiggo AND Epysqli is required.
For NMOSD: Trial and failure of Enspryng® and Uplizna® For PNH: Trial and failure of Empaveli® AND Epysqli 2025 2025 ✓

Q5153 Aflibercept-yszy Opuviz™ ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 8/1/2025 8/1/2025 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

49 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5153 Aflibercept-yszy Unbranded biosimilar ✓ Trial and failure of bevacizumab (Avastin®) or a bevacizumab biosimilar 10/27/2025 10/27/2025 ✓

Q5154 Omalizumab-igec Omlyclo® ✓ 10/1/2025 10/1/2025 ✓

Q5154 Omalizumab-igec Unbranded biosimilar ✓ 10/1/2025 10/1/2025 ✓

Q5155 Aflibercept-jbvf Yesafili™ ✓ 10/1/2025 10/1/2025 ✓

Q5156 Tocilizumab-anoh Avtozma® ✓ Trial and failure of Tyenne AND Trial and failure of Inflectra® or Avsola® These preferred drugs don’t require prior authorization.
Trial and failure of adalimumab AND Tyenne SC is also required for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage (MAPD). Note: Infliximab and adalimumab are not required for cytokine release syndrome or giant cell arteritis.
10/1/2025 10/1/2025 ✓

Q5157 Denosumab-bmwo Stoboclo® ✓ 6/1/2025 6/1/2025 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

50 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5157 Denosumab-bmwo Unbranded biosimilar ✓ Use the preferred denosumab biosimilar Stoboclo® 12/1/2025 12/1/2025 ✓

Q5158 Denosumab-bnht Conexxence® ✓ Use the preferred denosumab biosimilar Stoboclo® 10/1/2025 10/1/2025 ✓

Q5158 Denosumab-bnht Unbranded biosimilar ✓ Use the preferred denosumab biosimilar Stoboclo® 10/1/2025 10/1/2025 ✓

Q5158 Denosumab-bnht Bomyntra® ✓ Use the preferred denosumab biosimilar Osenvelt®
The preferred drug doesn’t require prior authorization. 12/1/2025 12/1/2025 ✓

Q5159 Denosumab-dssb Ospomyv™ ✓ Use the preferred denosumab biosimilar Stoboclo® 10/1/2025 10/1/2025 ✓

Q5159 Denosumab-dssb Unbranded biosimilar ✓ Use the preferred denosumab biosimilar Stoboclo® 10/1/2025 10/1/2025 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

51 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q5159 Denosumab-dssb Zbryk™ ✓ Use the preferred denosumab biosimilar Osenvelt®
The preferred drug doesn’t require prior authorization. 12/1/2025 12/1/2025 ✓

Q5160 Bevacizumab-nwgd Jobevne™ ✓ Use both of the following preferred bevacizumab biosimilar drugs: Zirabev® and Mvasi® 3/4/2026 3/4/2026

✓ Q5161 Denosumab-kyqq Bosaya™ ✓ Use the preferred denosumab biosimilar Stoboclo® 5/11/2026 5/11/2026 ✓

Q5161 Denosumab-kyqq Aukelso™ ✓ Use the preferred denosumab biosimilar Osenvelt® The preferred drug doesn’t require prior authorization. 5/11/2026 5/11/2026 ✓

Q5162 Denosumab-nxxp Bildyos® ✓ Use the preferred denosumab biosimilar Stoboclo® 1/2/2026 1/2/2026 ✓

Q5162 Denosumab-nxxp Bilprevda® ✓ Use the preferred denosumab biosimilar Osenvelt® The preferred drug doesn’t require prior authorization. 1/2/2026 1/2/2026 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

52 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q9997 Ustekinumab-ttwe Unbranded biosimilar IV ✓ Trial and failure of the following preferred ustekinumab drugs:
Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 10/1/2025 10/1/2025 ✓

Q9998 Ustekinumab-aekn Selarsdi™ IV ✓
Trial and failure of the following preferred ustekinumab drugs:
Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 7/1/2025 7/1/2025 ✓

Q9998 Ustekinumab-aekn Unbranded biosimilar IV ✓ Trial and failure of the following preferred ustekinumab drugs:
Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 10/1/2025 10/1/2025 ✓

Q9999 Ustekinumab-aauz Otulfi® IV ✓ Trial and failure of the following preferred ustekinumab drugs: Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 2025 2025 ✓

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

53 HCPCS codes Generic name Trade name Step therapy requirement Prior authorization requirement effective date Submit authorization request through Medicare Plus Blue BCN Advantage Medical and Pharmacy Drug PA Portal
OncoHealth Q9999 Ustekinumab-aauz Unbranded biosimilar IV ✓ Trial and failure of the following preferred ustekinumab drugs:
Steqeyma, Pyzchiva and Wezlana These preferred drugs don’t require authorization. 7/1/2025 7/1/2025 ✓

Revision history Date Revisions 5/1/2026 • Authorization requirement effective 6/22/2026: J2329 Briumvi, J3590 Enoby, J3590 Xtrenbo, J7606 Formoterol fumarate, J2350 Ocrevus, J2351 Ocrevus Zunovo, J7601 Ohtuvayre, J1599 Qivigy, Q5134 Tyruko, J2323 Tysabri, J7677 Yuperli 4/9/2026 • Authorization requirement effective 5/1/2026: J3590 Avlayah, J3590 Kresladi • Correction — Authorization requirement effective date is 5/11/2026, not 5/1/2026: J3590 Starjemza IV, J1569 Gammagard Liquid ERC, J3404 Papzimeos, Q5161 Aukelso, Q5161 Bosaya 4/1/2026 • Code updates effective 4/1/2026: J1553 Yimmugo, Q5162 Bildyos, Q5162 Bilprevda • Authorization requirement effective 4/1/2026: J9350 Lunsumio VELO, J3590 Loargys • Updates made to step therapy requirements for Vyvgart Hytrulo effective 4/1/2026 • Step therapy requirements added for Izervay effective 4/1/2026 • Authorization requirement removed effective 6/1/2026: J1412 Roctavian (withdrawn from U.S. market by manufacturer) • Authorization requirement effective 5/1/2026: J3590 Starjemza IV, J1569 Gammagard Liquid ERC, J3404 Papzimeos, Q5161 Aukelso, Q5161 Bosaya • Authorization requirement effective 5/13/2026: J9184 Avgemsi, J9054 Boruzu, J9183 Inlexo, J9277 Keytruda Qlex, J9278 Kyxata, J9601 Lynozyfic, J9056 Vivimusta 1/22/2026 • Authorization requirement removed effective 1/1/2026: Q5115 Truxima, Q5103 Inflectra • Authorization requirement effective 1/22/2026: J3358 Stelara • Authorization requirement effective 2/2/2026: J3590 Exdensur, J3590 Yartemlea • Updates made to step therapy requirements for Orencia, Cosentyx, Tofidence, Tyenne and the unbranded tocilizumab-aazg biosimilar effective 2/2/2026

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

54 Date Revisions 1/1/2026 • Authorization requirement effective 1/1/2026: Q5136 unbranded Jubbonti, Q5104 unbranded Renflexis • Authorization requirement effective 1/2/2026: J3590 Bildyos, J3590 Bilprevda • Code updates effective 1/1/2026: J9256 Imaavy, J3389 Zevaskyn • Authorization requirement effective 1/15/2026: J3590 Itvisma, J3590 Waskyra • Authorization requirement effective 3/4/2026: J9174 Beizray, J9172 Docivyx, J9326 Emrelis, J9301 Gazyva, Q5160 Jobevne, J9282 Zusduri 11/1/2025 • Authorization requirement effective 10/27/2025: J3590 Yummugo, Q5153 Aflibercept-yszy • Added preferred ustekinumab products effective 11/1/2025 • Authorization requirement removed effective 11/1/2025: Q5138 Wezlana, Q5138 ustekinumab-auub, Q5099 Steqeyma, Q9997 Pyzchiva, J3358 Stelara • Updates made to step therapy requirements effective 11/1/2025 for: Orencia, Cimzia, Simponi Aria, Tremfya IV, Omvoh IV, Skyrizi IV, Ilumya, Cosentyx IV, Bimzelx, Actemra, Tofidence, Avtozma, Tyenne, and Tocilizumab unbranded biosimilar • Corrected diagnosis code: J3590 Leqembi IQLIK • Authorization requirement effective 1/1/2026: J1454 Akynzeo, J0185 Cinvanti, J1434 Focinvez, J1627 Sustol • Added preferred eculizumab product effective 1/1/2026 • Added preferred tocilizumab product effective 1/1/2026 • Updates made to highlight changes to preferred agents effective 1/1/2026 • Update made to Entyvio step therapy requirements effective 11/1/2025 for members who have a prescription drug plan through Medicare Plus Blue or BCN Advantage. Ustekinumab is now required. 10/1/2025 • Authorization requirement effective 10/1/2025: Q5156 Avtozma, Q5158 Conexxence, Q5158 Denosumab-bnht, Q5154 Omlyclo, Q5154 Omalizumab-igec, Q5159 Ospomyv, Q5159 Denosumab-dssb, Q5155 Yesafili, Q9997 Ustekinumab-ttwe, Q9998 Ustekinumab- aekn, J0714 Leqembi IQLIK • Code updates effective 10/1/2025: J1809 Nulibry, J3402 Ryoncil, J3403 Encelto, J7174 Qfitlia, Q5157 Stoboclo • Update made to preferred botulinum toxins effective 10/1/2025 • Authorization requirement removed effective 10/1/2025: J0585 Botox • Added preferred denosumab biosimilar effective 12/1/2025 • Authorization requirement effective 12/1/2025: J9011 Datroway, J0897 Xgeva, Q5158 Bomyntra, Q5136 Wyost, Q5159 Xbryk, Q5157 denosumab-bmwo 8/1/2025 • Authorization requirement removed effective 8/1/2025: G2082 and G2083 Spravato • Authorization requirement removed effective 8/1/2025: J1414 Beqvez (no longer on the market in the U.S.) • Added step therapy criteria for Onivyde and Anktiva effective 12/1/2025 7/3/2025 • Authorization requirement removed effective 7/1/2025: J7601 Ohtuvayre

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

55 Date Revisions 7/1/2025 • Code updates effective 7/1/2025: J7172 Hympavzi, Q2058 Auctazyl, Q5098 Imuldosa, Q5099 Steqeyma, Q5100 Yesintek • Authorization requirement effective 7/1/2025: J3590 Imaavy, J3590 Zevaskyn, Q9999 Ustekinumab-aauz, Q5135 Tocilizumab-aazg • Authorization requirement effective 8/1/2025: Q5153 Opuviz • Authorization requirement effective 8/20/2025: J9382 Bizengri, J9289 Opdivo Qvantig, J9275 Uloxcyt, J1326 Vyloy, J9276 Ziihera • Authorization requirement effective 9/3/2025: J9210 Gamifant 5/1/2025 • Authorization requirement effective 6/1/2025: J3590 Qfitlia • Authorization requirement effective 7/1/2025: Q9998 Selarsdi 4/1/2025 • Code updates effective 4/1/2025: J1299 Soliris, Q2057 Tecelra, Q5152 Bkemv, Q9999 Otulfi, J9038 Niktimvo • Authorization requirement effective 5/1/2025: Q5147 Pavblu, Q5149 Enzeevu, Q5150 Ahzantive, Q5151 Epysqli • Added additional step therapy criteria effective 5/1/2025: Evenity, Entyvio, Vabysmo, Vyvgart, Vyvgart Hytrulo, Rystiggo • Added step therapy criteria for Herceptin Hylecta effective 5/12/2025 • Update made to preferred trastuzumab biosimilars effective 5/12/2025 • Authorization requirement effective 6/1/2025: Q5146 Hercessi, Q5148 Nypozi, J3590 Stoboclo, J3590 Encelto, J9024 Tecentriq Hybreza, J9161 Lymphir, J9028 Anktiva, J9026 Imdelltra • Authorization requirement changed from Novologix to OncoHealth effective 6/1/2025: J0870 Rytelo, J9038 Niktimvo
• Added step therapy requirements for Keytruda and Opdivo for nasopharyngeal cancer effective 6/18/2025 2/1/2025 • Authorization requirement effective 3/3/2025: J3590 Steqeyma IV, J3590 Ryoncil • Authorization requirement removed effective 2/1/2025: J9258 and J9259 paclitaxel protein-bound particles generic (no longer on the market in the U.S.) • Correction: An additional generic pemetrexed (J9292) was added to the list for 1/1/2025. 1/1/2025 • Authorization requirement effective 2/3/2025: J3590 Kebilidi, Q5139 Bkemv, Q9997 Pyzchiva IV, J3590 Niktimvo, J3590 Yesintek IV • Code updates effective 1/1/2025: J0870 Rytelo, J1307 PiaSky, J1414 Beqvez, J1552 Alyglo, J7601 Ohtuvayre, J3392 Casgevy, J2802 Nplate • Code correction: J3590 Omisirge, J9999 Aucatzyl
11/19/2024 • Authorization requirement effective 11/21/2024: J3590 Aucatzyl • Authorization requirement effective 1/6/2025: J3590 Hympavzi • Authorization requirement effective 2/3/2025: J3590 Imuldosa IV • Added additional step therapy criteria effective 2/3/2025 for Soliris, Ultomiris and Simponi Aria

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

56 Date Revisions 11/1/2024 • Updates made to highlight changes to preferred agents effective 1/1/2025 • Authorization requirement removed effective 11/1/2024: J1748 Zymfentra, J3490 Zilbysq • Authorization requirement effective 12/2/2024: J1628 Tremfya IV • Authorization requirement removed effective 1/1/2025: Q5123 Riabni
• Authorization requirement effective 1/1/2025: J9329 Tevimbra, Q5115 Truxima • Authorization requirement effective 1/6/2025: J3590 Otulfi IV • Authorization requirement changed from Novologix to OncoHealth effective 1/1/2025: J0896 Reblozyl, Q5108 Fulphila, Q5118 Zirabev, J1442 Neupogen, J1447 Granix, J1449 Rolvedon, J9035 Avastin, J9355 Herceptin, J9361 Ryzneuta, Q5111 Udenyca and Udenyca Onbody, Q5112 Ontruzant, Q5113 Herzuma, Q5116 Trazimera, Q5120 Ziextenzo, Q5125 Releuko, Q5126 Alymsys, Q5127 Stimufend, Q5129 Vegzelma, Q5130 Fylnetra
10/1/2024 • Code update effective 10/1/2024: Q5135 Tyenne • Authorization requirement effective 11/3/2024: Q5136 Jubbonti, Q5138 Wezlana IV 9/9/2024 • CORRECTION Authorization requirement effective 10/1/2024: J3590 PiaSky, J3590 Tecelra 9/1/2024 • Authorization requirement effective 9/1/2024: J3590 PiaSky, J3590 Tecelra
• Code correction: J3490 Rytelo • Added step therapy requirements for immune globulin products effective 11/1/2024
• Authorization requirement removed effective 1/31/2024: J0257 Glassia 8/1/2024 • Authorization requirement effective 8/1/2024: J9999 Rytelo 7/12/2024 • Authorization requirement effective 7/15/2024: J0175 Kisunla, J7699 Ohtuvayre 7/1/2024 • Code update effective 7/1/2024: J1748 Zymfentra, J2267 Omvoh IV, J3247 Cosentyx IV, J3393 Zynteglo, J3394 Lyfgenia, J7171 Adzynma, J9361 Ryzneuta • Added additional step therapy criteria effective 9/16/2024 for Soliris and Ultomiris

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

57 Date Revisions 6/1/2024 • Authorization requirement effective 6/1/2024: J3590 Beqvez • Authorization requirement effective 7/1/2024: J1747 Spevigo SC, J3590 Tyenne • Authorization requirement effective 8/15/2024: J3263 Loqtorzi • Authorization requirement removed effective 6/1/2024: J0588 Xeomin • Step therapy requirement of preferred botulinum toxin added effective 8/5/2024: J0585 Botox, J0586 Dysport, J0587 Myobloc, J0589 Daxxify • Added step therapy criteria effective 8/1/2024 for Pemrydi RTU • Added step therapy criteria effective 9/1/2024 for Saphnelo 5/1/2024 • Authorization requirement effective 5/1/2024: J3590 Winrevair 4/1/2024 • Code update effective 4/1/2024: J1203 Pombiliti, J9376, Veopoz, J0177 Eylea HD, J2782 Izervay, J0589 Daxxify • Authorization requirement effective 5/1/2024: Q5133 Tofidence • Authorization requirement effective 6/20/2024: J3055 Talvey, J1323 Elrexfio • Step therapy requirement of preferred ERT added effective 6/1/2024: J3395 VPRIV, J3060 Elelyso • Authorization requirement removed effective 1/1/2024: J1786: Cerezyme
3/5/2024 • Authorization requirement removed effective 3/1/2024: J3590 Entyvio SC, J3590 Omvoh SC • Code correction: J3490 Omisirge • Authorization requirement effective 4/1/2024: J1599 Alyglo, Q5111 Udenyca Onbody, J3590 Amtagvi, J3590 Avzivi, J3590 Ryzneuta 3/1/2024 • Updates to Soliris, Ultomiris to reflect changes in step therapy requirements effective 3/1/2024. • Updated Soliris, Ultomiris and Zilbrysq to reflect changes to step therapy requirements effective 4/1/2024. • Code correction for Entyvio SC back to J3590 • Added step therapy criteria for Pemfexy effective 4/26/2024

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

58 Date Revisions 2/1/2024 • Authorization requirement effective 3/1/2024: J3590 Adzynma, J3490 Wainua • Code correction: J3380 Entyvio SC • Updated step therapy requirements for Eylea HD • Authorization requirement effective 2/1/2024: J1572 Flebogamma is once again available in the U.S. • Authorization requirement removed effective 1/31/2024: J0256 Aralast, Prolastin C and Zemaira 1/1/2024 • Authorization requirement removed effective 12/31/2023: J9027 Aliqopa (no longer on the market in the U.S.) • Authorization requirement effective 1/1/2024: J9258 Paclitaxel protein-bound particles, J9324 Pemrydi RTU • Prior authorization changed from Novologix to Carelon effective 1/1/2024: Q5122 Nyvepria, Q5114 Ogivri • Prior authorization changed from Carelon to Novologix effective 1/1/2024: Q5118 Zirabev, Q5108 Fulphila, Q5120 Ziextenzo, Q5116 Trazimera • Infliximab step added effective 1/1/2024: J0717 Cimzia and J2327 Skyrizi IV
• Infliximab step removed effective 1/1/2024: J3245 Ilumya • Authorization requirement effective 1/2/2024: Lyfgenia and Casgevy (both have code J3590) • Code update effective 1/2/2024: J0217 Lamzede, J1304 Qalsody, J1412 Roctavian, J1413 Elevidys, J2508 Elfabrio, J3401 Vyjuvek, J9333 Rystiggo, J9334 Vyvgart Hytrulo • Authorization requirement effective 2/1/2024: C9399 Omisirge • Authorization requirement effective 2/12/2024: J3590 Bimzelx, J3590 Cosentyx IV, J3590 Entyvio SC, J3590 Omvoh, J3590 Pombiliti, J3590 Zymfentra, J3490 Rivfloza, J3490 Zilbrysq • Authorization requirement effective 3/1/2024: J9286, Columvi, J9321 Epkinly 11/1/2023 • Authorization requirement effective 12/18/2023: J3490 Daxxify • Updates made to highlight changes to preferred agents effective 1/1/2024 • Prior authorization requirement removed 1/1/2024: Q5104 Renflexis, Q5115 Truxima • Prior authorization requirement added effective 1/1/2024: Q5103 Inflectra, Q5123 Riabni

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

59 Date Revisions 9/5/2023 • Authorization requirement effective 10/15/2023: Veopoz, Lantidra (both have code J3590); Izervay, Eylea HD (both have code J3490); and J1745 generic infliximab (non-biosimilar) • Authorization requirement effective 12/10/2023: J9345 Zynyz • Code update effective 10/1/2023: J2781 Syfovre • Authorization requirement removed effective 9/30/2023: J9313 Lumoxiti® (no longer on the market in the U.S.) 8/7/2023 • Byooviz step therapy requirement removed effective 7/27/2023: J0178 Eylea • Code change with a retroactive effective date of 7/6/2023: J0174 Leqembi 7/10/2023 • Authorization requirement effective 7/10/2023: Elevidys, Roctavian and Rystiggo (all have code J3590) and J3490 Vyvgart Hytrulo 7/1/2023 • Code updates effective 7/1/2023: J1440 Rebyota, J1576 Panzyga, J9381 Tzield, J9029 Adstiladrin, • Authorization requirement effective 7/1/2023: J9321, J9322, J9323 Pemetrexed generic various manufacturers, J9259 paclitaxel protein-bound particles (generic brand) • Authorization requirement effective 8/1/2023: J3590 Qalsody • Authorization requirement effective 8/14/2023: Vyjuvek and Elfabrio both are J3590 • Authorization requirement effective 8/23/2023: J9063 Elahere, J9350 Lunsumio, J9380 Tecvayli, J9347 Imjudo,
5/1/2023 • Updates to Eylea to reflect changes in step therapy requirements • Updates to Cinqair and Tezspire to reflect changes in step therapy requirements • Corrected code for Rebyota to J3490 4/1/2023 • Code updates effective 4/1/2023: Q5127 Stimufend, Q5128 Cimerli, Q5129 Vegzelma, Q5130 Fylnetra, J1747 Spevigo, J1411 Hemgenix, J1449 Rolvedon, J0218 Xenpozyme • Additional codes added for various brands of generic pemetrexed: J9294, J9296, and J9297 • Corrected code for Syfovre to J3490 • Authorization requirement effective 5/1/2023: J3590 Lamzede 3/8/2023 • Authorization requirement removed effective 4/1/2023: J2503 Macugen (no longer on the market in the U.S.) • Authorization requirement removed effective 4/1/2023: J0775 Xiaflex • Authorization requirement effective 5/1/2023: J3590 Adstiladrin • Authorization requirement effective 4/3/2023: J3590 Syfovre

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

60 Date Revisions 2/6/2023 • Authorization requirement effective 3/1/2023: Rolvedon, Stimufend, Vegzelma, Rebyota (all have code J3590) 1/9/2023 • Authorization requirement effective 1/13/2023: J3590 Leqembi • Byooviz step therapy requirement removed effective 1/9/2023: J2778 Lucentis 1/1/2023 • Code updates effective 1/1/2023: J0225 Amvuttra, J2327 Skyrizi IV, Q5126 Alymsys
• Authorization requirement effective 1/1/2023: J9314 generic pemetrexed • Authorization requirement removed effective 1/1/2023: J9037 Blenrep (no longer on the market in the U.S.) • Authorization requirement removed for oncology drugs effective 1/1/2023: J9042 Adcetris, J9302 Arzerra, J9118 Asparlas, J9036 Belrapzo, J9034 Bendeka, J9229 Besponsa, J9039 Blincyto, J9308 Cyramza, Q2050 Doxil, Q2049 Lipodox, J9246 Evomela, J9301 Gazyva, J9179 Halaven, J9325 Imlygic, J9318 and J9319 Istodax, J9207 Ixempra, J9043 Jevtana, J9047 Kyprolis, J2562 Mozobil, J9203 Mylotarg, J9295 Portrazza, Q2043 Provenge, J2860 Sylvant, J9033 Treanda, J9999 Unituxin, J0897 Xgeva, J9400 Zaltrap, J9223 Zepzelca 12/2/2022 • Authorization requirement effective 12/2/2022: J3590 Hemgenix • Authorization requirement effective 12/2/2022: J3590 Tzield 12/1/2022 • Authorization requirement effective 12/19/2022: J3590 Fylnetra • Authorization requirement effective 2/9/2023: J9304 Pemfexy • Infliximab step therapy requirement removed effective 12/19/2022: J3590 Skyrizi IV 11/1/2022 • Authorization requirement effective 11/1/2022: Xenpozyme and Zynteglo (both have code J3590) 10/3/2022 • Code updates effective 10/1/2022: C9142 Alymsys, J1302 Enjaymo, J2777 Vabysmo, J9274 Kimmtrak, Q2056 Carvykti, Q5125 Releuko • Authorization requirement effective 9/26/2022: J3590 Spevigo • Authorization requirement effective 10/3/2022: J3590 Cimerli • Authorization requirement effective 12/1/2022: J9298 Opdualag 8/10/2022 • Date correction – Authorization requirement removal date changed from 8/1/2022 to 8/15/2022: J3357 Stelara SC • Authorization requirement removed effective 8/15/2022: J3590 Skyrizi SC

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

61 Date Revisions 8/1/2022 • Authorization requirement effective 8/1/2022: J3590 Skyrizi IV formulation • Authorization requirement effective 8/8/2022: J3490 Amvuttra, J3590 Releuko and J9999 Alymsys
• Authorization requirement removed effective 8/1/2022: J3357 Stelara SC • Infliximab step therapy requirement removed effective 8/1/2022: J3358 Stelara IV 7/1/2022 • Code updates effective 7/1/2022: C9094 Enjaymo, C9095 Kimmtrak, C9097 Vabysmo, C9098 Carvykti, J1306 Leqvio, J1551 Cutaquig, J2356 Tezspire, J2779 Susvimo, J2998 Ryplazim, J9332 Vyvgart • Prior authorization requirement added effective 8/8/2022: J1437 Monoferric, J1439 Injectafer 5/16/2022 • Authorization requirement removed effective 5/31/2022: J0641 Fusilev® (no longer on the market in the U.S.) • Authorization requirement effective 8/16/2022: J9331 Fyarro 4/12/2022 • Clarifications made to codes: J9999 Kimmtrak and Unituxin, J3490 Nulibry 4/1/2022 • Edits made to clarify preferred products effective 4/1/2022. 3/9/2022 • Authorization requirement effective 3/7/2022: J9999 Carvykti • Code updates effective 4/1/2022: C9090 Ryplazim, C9093 Susvimo, J0219 Nexviazyme, J0491 Saphnelo, J9359 Zynlonta, Q5124 Byooviz • Authorization requirement added effective 5/23/2022: J9273 Tivdak, J3590 Kimmtrak 3/3/2022 • Authorization requirement added effective 3/7/2022: Enjaymo and Vabysmo (both have code J3590) • Authorization requirement added effective 6/6/2022: J3590 Byooviz
• Prior authorization requirement removed 4/1/2022: Q5121 Avsola • Prior authorization requirement added effective 4/1/2022: Q5104 Renflexis • Prior authorization changed from Novologix to AIM: Q5108 Fulphila, Q5120 Ziextenzo • Prior authorization changed from AIM to Novologix: Q5111 Udenyca 2/7/2022 • Authorization requirement added effective 2/21/2022: J3490 Tezspire • Authorization requirement added effective 3/1/2022: J3490 Vyvgart and Leqvio

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

62 Date Revisions 1/1/2022 • Code updates effective 1/1/2022: C9085 Nexviazyme, J0172 Aduhelm, J2506 Neulasta, J9061 Rybrevant, J9272 Jemperli, Q2055 Abecma, C9086 Saphnelo • Authorization requirement added effective 1/17/2022: J3590 Ryplazim 11/29/2021 • Authorization requirement removed: J9247 Pepaxto (no longer on the market in the U.S.) • Authorization requirement removed effective 12/1/2021: J3490 Tegsedi • Authorization requirement added effective 12/27/2021: J3590 Susvimo 10/4/2021 • Code update effective 10/1/2021: Q2054 Breyanzi, J1305 Evkeeza, J9318 and J9319 Istodax, J9247 Pepaxto, J1448 Cosela, C9084 Zynlonta, C9083 Rybrevant, C9082 Jemperli, C9081 Abecma • Code correction: Nexviazyme changed to J3590 • Authorization requirement removed: J1572 Fleboggamma (no longer on the market in the U.S.) 9/1/2021 • Authorization requirement added effective 9/1/2021: J3490 Nexviazyme, J3590 Saphnelo 8/9/2021 • Authorization requirement added effective 9/13/2021: J2793 Arcalyst • Authorization requirement added effective 9/27/2021: J3490, J3590, J9999, C9399 Rybrevant • Code update effective 9/1/2021 to indicate Spravato plus observation: G2082 and G2083 6/8/2021 • Authorization requirement added effective 6/8/2021: J3590 Aduhelm • Authorization requirement added effective 6/14/2021: J3490, J3590 Empaveli • Authorization requirement added effective 7/26/2021: Jemperli and Zynlonta (both have codes J3490, J3590, J9999, C9399) • Code update effective 7/1/2021: J9348 Danyelza, J9353 Margenza, J0224 Oxlumo, C9080 Pepaxto, C9079 Evkeeza, C9078 Cosela, C9076 Breyanzi • Authorization requirement removed effective 6/8/2021: J2504 Adagen (no longer on the market in the U.S.) 5/10/2021 • Code update effective 4/1/2021: Visco-3 once again shares code J7321 with Hyalgan 5/3/2021 • Authorization requirement added effective 5/24/2021: Cosela and Pepaxto (both have codes J3490, J3590, J9999, C9399) • Authorization requirement added effective 6/22/2021: C9074 Oxlumo; Evkeeza and Nulibry (both have codes C9399, J3490, J3590)

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

63 Date Revisions 4/1/2021 • Code update effective 4/1/2021: Q2053 Tecartus • Authorization requirement added effective 4/5/2021: J9999 Abecma • Statement added that J9035 Avastin does not require prior authorization for use in retinal disorders. 3/7/2021 • Authorization request submissions moving from AIM to NovoLogix effective 4/1/2021: J1442 Neupogen, J1447 Granix, J9035 Avastin, J9355 Herceptin, Q5113 Herzuma, Q5114 Ogivri, Q5112 Ontruzant, Q5108 Fulphila, Q5120 Ziextenzo, Q5122 Nyvepria
• Authorization requirement added effective 4/1/2021: J9312 Rituxan, Q5115 Truxima
• Authorization requirement added effective 4/22/2021: Danyelza and Margenza (both have codes J3490, J3590, J9999, C9399) • Code updates effective 4/1/2021: J1427Viltepso, J1554 Asceniv, J9037 Blenrep, J9349 Monjuvi 2/15/2021 • Authorization requirement added effective 2/11/2021: J9999 Breyanzi • Code update effective 1/1/2021: S0013 Spravato 12/26/2020 • Code updates effective 1/1/2021: J1823 Uplizna, J7352 Scenesse, J9144 Darzalex Faspro, J9223 Zepzelca, J9281 Jelmyto, J9316 Phesgo, J9317 Trodelvy, Q5122 Nyvepria, C9069 Blenrep, C9070 Monjuvi, C9071 Viltepso, C9072, Asceniv, C9073 Tecartus 10/30/2020 • Authorization requirement added effective 11/20/2020: Blenrep and Monjuvi (both have codes J3490, J3590, J9999, C9399), • Authorization requirement added effective 1/1/2021: Tecartus (J9999) and Viltepso (J3490, J3590) • Authorization requirement removed effective 11/20/2020: Lartruvo (J9285) 9/22/2020 • Code updates effective 10/1/2020: C9062 Darzalex Faspro, C9064 Jelmyto, C9066 Trodelvy, J3032 Vyepti, J3241 Tepezza, J9227 Sarclisa
8/5/2020 • Authorization requirement added effective 9/28/2020 for: J0638 Ilaris; J1558 Xembify; J1599 Cutaquig • Authorization requirement added effective 9/25/2020 for: Zepzelca, Phesgo, Nyvepria (all have codes J3490, J3590, J9999) • Step therapy requirements added to list for: J3245 Ilumya, J3590 Skyrizi
• Addition of preferred filgrastim biosimilar step therapy requirement for: J1442 Neupogen, J1447 Granix 6/29/2020 • Authorization requirement added effective 7/9/2020 for: Abicipar pegol • Authorization requirement added effective 8/21/2020 for: Roctavian, Uplizna (both have code J3590); Q5121 Avsola • Authorization requirement removed effective 8/1/2020 for: J1740 Boniva, J2430 Aredia

Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM and BCN AdvantageSM members Revised May 2026

64 Date Revisions 6/12/2020 • Code updates effective 7/1/2020: C9061 Tepezza, C9063 Vyepti, J0223 Givlaari, J0791 Adakveo, J0896 Reblozyl, J1429 Vyondys 53, J3399 Zolgensma, J7333 Visco-3, J9177 Padcev, J9358 Enhertu, Q5120 Ziextenzo • Authorization requirement added effective 7/24/2020 for: Trodelvy, Jelmyto, Darzalex Faspro (all have codes J3490, J3590, J9999); J9325 Imlygic
5/15/2020 • Step therapy requirements added to list for: J3262 Actemra, J3357 Stelara SQ, J3358 Stelara IV, J3590 Vyepti,
J0129 Orencia and J3380 Entyvio 4/2/2020 • Authorization requirement added effective 6/15/2020 for: J1428 Exondys 51, J3490 Vyondys 53, C9056 and J3490 Givlaari, J3590 Tepezza, J3590 Vyepti • Authorization requirement added effective 5/15/2020 for: J3590 Sarclisa • Code update: C9058 Ziextenzo • Authorization requirement removed effective 4/3/2020 for: Q5103 Inflectra, Q5104 Renflexis, Q5109 Ixifi
2/26/2020 • Authorization requirement added effective 4/1/2020 for: Enhertu; Padcev; Ziextenzo (all have codes J3490, J3590, J9999) • Certain oncology medications: Removed information about submitting authorization requests through NovoLogix for dates of service on or before 12/31/2019 2/16/2020 • Authorization requirement added effective 3/16/2020 for: J3590 Reblozyl; J3490 Scenesse; J3590 Adakveo; J9036 Belrapzo; J9039 Polivy; J9118 Asparlas; J9313 Lumoxiti; J9356 Herceptin Hylecta; Q5116 Trazimera; Q5117 Kanjiti; Q5118 Zirabev • Authorization requirement removed effective 3/2/2020 for: J3489 Reclast, Zometa
• Effective date changed for: Q2041 Yescarta; Q2042 Kymriah

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