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Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the BlueCross BlueShield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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Medical specialty injectable drugs

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. Benefit eligibility and payment are subject to member and benefit eligibility at the time of service, limitations and conditions outlined in the member’s Benefits Booklet (Certificate of Coverage), and medical necessity of the requested service as determined by 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.

Policy name	Action	Effective date	Highlights
Denosumab	Revised	October 1, 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	Revised	October 1, 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	Revised	October 1, 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.
Gemcitabine	Revised	October 1, 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	Revised	October 1, 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	Revised	October 1, 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	Revised	December 1, 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	Revised	December 1, 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.
Bendamustine	Revised	December 1, 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	Revised	January 1, 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.

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Medical specialty injectable drugs

Policy name

Action

Effective date

Highlights