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Medical Policy Updates: Drug Step Therapy for Medicare Advantage Members

Effective January 1, 2021, Horizon BCBSNJ will change the way we process and reimburse claims for certain drugs for patients enrolled in our Medicare Advantage plans based on the following medical policies:

  • Vascular Endothelial Growth Factor Inhibitor and Human Epidermal Growth Factor Receptor Inhibitor
  • Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri), Ado-trastuzumab emtansine (Kadcyla), Trastuzumab-pkrb (Herzuma), Trastuzumab-dttb (Ontruzant), Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta), Trastuzumab-qyyp (Trazimera), Trastuzumab-anns (Kanjinti), Fam-trastuzumab deruxtecan-nxki (Enhertu), Pertuzumab (Perjeta), and Pertuzumab, Trastuzumab, and hyaluronidase-zzxf (Phesgo)
  • Rituximab (Rituxan), Rituximab-abbs (Truxima), Rituximab-pvvr (Ruxience) and Rituximab/hyaluronidase (Rituxan Hycela)
  • Bendamustine Hydrochloride (Treanda®, Bendeka®, Belrapzo)
  • Eculizumab (Soliris) and Ravulizumab-cwvz (Ultomiris)
  • Paclitaxel Protein-Bound Particles (Abraxane)
  • Levoleucovorin (Fusilev and Khapzory)
  • Gemcitabine in sodium chloride injection (Infugem)
  • Granulocyte Colony Stimulating Factor (G-CSF - Neupogen, Neulasta, Granix, Zarxio, Fulphila, Nivestym, Udenyca, Ziextenzo, Nyvepria) and Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF - Leukine)

Access our Medical Policy Manual to review the content of these medical policies.

Beginning January 1,2021, patients enrolled in our Medicare Advantage plans who are newly prescribed certain brand name drugs (listed below column 2) will, in some cases, be required to first try a Preferred alternative agent (listed below in column 3) to treat his or her medical condition before we will cover another drug for that condition.

If the Preferred alternative agent not effective in treating your Medicare Advantage patient’s condition, we will then cover the requested drug.

HCPCS Requested Product Preferred Alternative Agent(s)
J9035 Avastin® Mvasi™, Zirabev®
J9355 Herceptin® Kanjinti™, Ogivri™, Trazimera™
Q5113 Herzuma® Kanjinti™, Ogivri™, Trazimera™
Q5112 Ontruzant® Kanjinti™, Ogivri™, Trazimera™
J9312 Rituxan® Truxima®, Ruxience®
J9033 Treanda® Bendeka®, Belrapzo™
J1300 Soliris® Ultomiris®
J9264 Abraxane® Paclitaxel (off-label uses only)
J0641, J0642 Fusilev®, Khapzory™ leucovorin
J9198 Infugem™ gemcitabine
Q5120 Ziextenzo® Neulasta®, Fulphila®, Udencya®

This requirement will help encourage Medicare Advantage members to try equally effective and safe products that will cost less.

If your Medicare Advantage patients have questions about this program, please direct them to our Part B Step Therapy webpage or encourage them to call Member Services.

CPT® is a registered mark of the American Medical Association.

Published on: October 1, 2020, 05:35 a.m. ET
Last updated on: April 27, 2021, 03:51 a.m. ET