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Blue Cross Blue Shield of Rhode IslandTraditional Medicare · Prior Auth · Physician · RI · Oncology, Ophthalmology, Rheumatology +2 moreHigh impact

Step therapy drug update for Medicare – Effective January 1, 2022

Act
immediately
Effective date
Jan 1, 2022
Identified
Jun 19, 2026

Summary

Effective January 1, 2022, Medicare now requires step therapy documentation for multiple high-cost specialty drugs, meaning providers must document trial and failure of specific lower-cost alternatives before prescribing certain medications. Nine drugs also require new prior authorization in addition to step therapy requirements.

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What to do

immediately · 4 steps
01Billing team and providers must update workflows to document trial and failure of specified step therapy drugs before prescribing covered alternatives.
02Update EMR templates to capture required step therapy documentation for all affected HCPCS codes.
03Ensure prior authorization is obtained for nine newly required drugs (Monvisc, Synvisc, Hyalgan, Gelsyn, Supartz, Genvisc, Trvisc, Hymovis, Triluron).
04Claims will be denied without proper step therapy documentation.

Codes mentioned

J9355J9312Q5119J9310J0178J0179J2778J0897J7327J7325J7321J7328J7320J7329J7322J7332Q5104Q5122Q5108Q5120J1930

Original notice

Step therapy drug update for Medicare – Effective January 1, 2022
bcbsri.com · Always check the source before changing claims.
View original ↗

Related changes

See all Blue Cross Blue Shield of Rhode Island changes →
Drugs moving from the specialty pharmacy benefit to the medical benefit 4/1/21HighEffective Apr 1, 2021 · PhysicianJanuary 2017MediumNo effective date · Provider UpdateCPT® and HCPCS Level II code changesHighEffective Jan 1, 2019 · Physician / FacilityCPT code changesHighEffective Jul 1, 2020 · Physician / FacilityBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list

Related policy hubs

Blue Cross Blue Shield of Rhode Island policiesRI policy changesOncologyOphthalmologyRheumatologyOrthopedicsHematologyCode J9355Code J9312Code Q5119Code J9310Code J0178Code J0179Code J2778Code J0897Code J7327Code J7325Code J7321Code J7328Code J7320Code J7329Code J7322Code J7332Code Q5104Code Q5122Code Q5108Code Q5120Code J1930

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