Medicamentos inyectables especiales

Medical specialty injectable drugs are administered by a healthcare provider through an injection or infusion at a provider's office, healthcare facility, or a patient's home. These drugs may require specialized handling, storage, or monitoring by a healthcare provider.

This drug category is typically covered through your medical coverage rather than your prescription drug coverage.

Prime Therapeutics LLC (Prime), on behalf of Capital Blue Cross, provides services related to medical specialty injectable drugs, including medical policy management. From time to time, Capital Blue Cross and Prime update medical specialty injectable drug policies, including preauthorization requirements such as step therapy. Step therapy may require you to try a different drug first before approval of coverage is available for another medication.

The following chart lists recent updates to these policies. To learn more about coverage criteria, including Drug Infusion Site of Service requirements (which may require certain drugs to be administered at specific locations or facilities for you to receive coverage through your plan), review Prime’s medical drug policies.

Please note that preauthorization is not a guarantee of payment. La elegibilidad y el pago de los beneficios están sujetos al miembro y a la elegibilidad de los beneficios al momento del servicio, a las limitaciones y condiciones descritas en el Cuadernillo de beneficios del miembro (Certificado de cobertura) y a la necesidad médica del servicio solicitado según lo determine Capital.

The summaries below are high-level descriptions of policy changes and do not include all coverage criteria, limitations, exceptions, or clinical requirements. Members and providers should review the applicable medical policy for complete criteria.

Nombre de la política
Acción
Fecha de entrada en vigencia
Destacado

Denosumab

Revisado

1 de octubre de 2026

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to Bildyos and Enoby prior to using other Prolia products.
  • Member must try and fail, or have contraindication to Xtrenbo and Bilprevda prior to using other Xgeva products.

Tocilizumab

Revisado

1 de octubre de 2026

Revised step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to Tyenne AND Avtozma prior to using other Tocilizumab products.

Long-Acting Granulocyte Stimulating Factors

Revisado

1 de octubre de 2026

Revised step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to Fulphila OR Udenyca prior to using other pegfilgrastim products.

Gemcitabina

Revisado

1 de octubre de 2026

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail, or have contraindication to gemcitabine and Gemzar before using Avgemsi.

Inlexzo

Revisado

1 de octubre de 2026

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to gemcitabine and Gemzar before using Inlexzo.

Kyxata

Revisado

1 de octubre de 2026

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to carboplatin before using Kyxata.

Pemetrexed

Revisado

1 de diciembre de 2026

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to Pemtrexed and Alimta before using Pemfexy, Pemrydi, or Axtle.

Bortezomib

Revisado

1 de diciembre de 2026

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to Velcade prior to using other bortezomib products.

Bendamustina

Revisado

1 de diciembre de 2026

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to Treanda before using other bendamustine products.

Saphnelo

Revisado

1 de enero de 2027

New step therapy requirement for new starts or current utilizers:

  • Member must try and fail or have contraindication to self-administered Saphnelo, and where indicated Benlysta IV or subcutaneous Benlysta

On behalf of Capital Blue Cross, Prime Therapeutics LLC, an independent company, provides medical specialty drug management services.