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Medical/Pharmacy Policy Updates Effective 12/15/2026
Effective date
Dec 15, 2026
Identified
Sep 11, 2026
Summary
Blue Cross and Blue Shield of Nebraska (BCBSNE) has implemented a new step therapy requirement for six biologic drug classes effective 12/15/2026. Patients on non-preferred products (biosimilars and brand-name biologics) now require prior authorization and documented evidence of contraindication, intolerance, or failure to a preferred product before coverage. This affects denosumab, infliximab, rituximab, tocilizumab, and trastuzumab products across all patient populations.
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What to do
Action · 7 steps
01By 12/15/2026: Billing and clinical teams must implement the following changes.
02Update billing system to flag ALL claims for the non-preferred biologic products listed in policy MPC X.242 (HCPCS codes Q5162, Q5136, Q5157, Q5161, Q5167, Q5171, Q5166, Q5173, Q5159, Q5121, Q5103, Q5104, Q5119, Q5115, Q5123, Q5135, Q5156, Q5117, Q5116, Q5113, Q5146, Q5114, Q5112, and J-codes J0897, J1745, J9312, J9311, J3262, J3590, J9355, J9356) as requiring prior authorization for BCBSNE plans.
03Establish a prior authorization workflow that REQUIRES providers to document one of the following BEFORE claim submission: patient contraindication to preferred product, documented intolerance, or documented clinical failure.
04For new-start AND established patients, step therapy requirements apply equally.
05Update encounter templates and order entry systems to prompt providers to attach step therapy documentation at time of prescribing.
06Train billing staff to deny and return claims lacking required step therapy documentation.
07Claims submitted without prior authorization and step therapy evidence will be denied for non-preferred products.
Codes mentioned
Q5162Q5136Q5157Q5161Q5167Q5171Q5166Q5173Q5159J0897Q5121Q5103J1745Q5104Q5119Q5115Q5123J9312J9311Q5135Q5156J3262J3590Q5117Q5116Q5113J9355Q5146Q5114Q5112J9356
Original notice
Medical/Pharmacy Policy Updates Effective 12/15/2026
nebraskablue.com · Always check the source before changing claims.
Related changes
See all Blue Cross Blue Shield of Nebraska changes →Related policy hubs
Blue Cross Blue Shield of Nebraska policiesNE policy changesRheumatologyOncologyHematologyInfectious DiseasePharmacyCode Q5162Code Q5136Code Q5157Code Q5161Code Q5167Code Q5171Code Q5166Code Q5173Code Q5159Code J0897Code Q5121Code Q5103Code J1745Code Q5104Code Q5119Code Q5115Code Q5123Code J9312Code J9311Code Q5135Code Q5156Code J3262Code J3590Code Q5117Code Q5116Code Q5113Code J9355Code Q5146Code Q5114Code Q5112Code J9356