Boletín administrativo: 2026-08-002 Medicare Only

Date: August 1, 2026

Los temas tratados en este boletín administrativo aplican a:

Proveedores profesionales y de centros

A menos que se indique lo contrario, si tiene alguna pregunta relacionada con la información de este boletín, comuníquese con su asesor para proveedores o visite capbluecross.com/wps/portal/cap/provider/pec-look-up e ingrese su NPI o ID tributaria para identificar su punto de contacto designado en Capital Blue Cross.

Proveedores profesionales y de centros

Capital Blue Cross step therapy requirements for Medicare outpatient (Part B) medications

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

KEY POINT: Updates have been made to Capital Blue Cross’ policy for Medicare outpatient (Part B) medications by our vendor, Prime Therapeutics.

Please share these changes with your office staff, as they could impact step therapy preauthorization requests for our Medicare Advantage members.

Prime Therapeutics Medicare Advantage (Step therapy)
Drug name/Code
Acción
Fecha de entrada en vigencia
Change/Update

Armlupeg (Q5169)

Revisado

9/1/2026
  • Updated non-preferred products.

Exdensur (J2361)

Revisado

9/1/2026
  • Updated non-preferred products.

Nufymco (Q5168)

Revisado

9/1/2026
  • Updated non-preferred products.

Eydenzelt (Q5170)

Revisado

9/1/2026
  • Updated non-preferred products.

Kyxata (J9278)

Nuevo

10/1/2026
  • Added to step therapy policy.
  • Require Trial/Failure Carboplatin (J9045).

Avgemsi (J9184)

Nuevo

10/1/2026
  • Added to step therapy policy.
  • Require Trial/Failure Gemcitabine (J9196).

Inlexzo (J9183)

Nuevo

10/1/2026
  • Added to step therapy policy.
  • Require Trial/Failure Gemcitabine (J9196).

Fulphila (Q5108)

Revisado

10/1/2026
  • Moved to step therapy preferred alternative list.

Neulasta (J2506)

Revisado

10/1/2026
  • Moved to step therapy non-preferred product list.
  • Use Fulphila (Q5108) or Udenyca (Q5111) as the preferred alternative.

For more information, see Capital’s Step Therapy Criteria for Medicare Part B Drugs.