Medicare AdvantagePrior AuthHigh impact
AB2026-08-002 Medicare only
Capital Blue Cross·Oncology, Hematology·Provider News
Effective date
Sep 1, 2026
We identified it
Jul 31, 2026
Summary
Capital Blue Cross has updated step therapy requirements for Medicare Advantage Part B medications effective September 1 and October 1, 2026. Four drugs have revised non-preferred product lists (Armlupeg, Exdensur, Nufymco, Eydenzelt), three new drugs require trial/failure of specific alternatives (Kyxata, Avgemsi, Inlexzo), and Fulphila moved to preferred status while Neulasta moved to non-preferred status. Billing teams must implement these step therapy changes to avoid claim denials for Medicare Advantage members.
Action Required
By August 15, 2026: Billing team must update step therapy protocols in billing system and EMR templates for all Medicare Advantage claims. Implement the following requirements: (1) For claims dated on/after 9/1/2026, apply updated non-preferred product lists for Q5169 (Armlupeg), J2361 (Exdensur), Q5168 (Nufymco), and Q5170 (Eydenzelt) per Prime Therapeutics guidance; (2) For claims dated on/after 10/1/2026, add mandatory trial/failure requirements—J9278 (Kyxata) requires prior trial of J9045 (Carboplatin), J9184 (Avgemsi) and J9183 (Inlexzo) both require prior trial of J9196 (Gemcitabine); (3) Change Q5108 (Fulphila) to preferred alternative status and move J2506 (Neulasta) to non-preferred with Q5108 or Q5111 (Udenyca) as required alternatives. Providers must document trial/failure of required drugs before requesting authorization for new agents. Update preauthorization request forms and staff training materials. Contact Prime Therapeutics or your Provider Engagement Consultant for detailed step therapy criteria. Failure to implement these changes will result in claim denials for non-compliant requests.