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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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Administrative bulletin: 2026-08-002 Medicare Only

Date: August 1, 2026

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

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

Unless otherwise noted, if you have any questions regarding the information in this bulletin, please contact your Provider Engagement Consultant or visit capbluecross.com/wps/portal/cap/provider/pec-look-up and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.

Professional and facility Providers

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

CHIP

FEP PPO

Medicare Advantage HMO

Traditional and Comprehensive

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	Action	Effective date	Change/Update
Armlupeg (Q5169)	Revised	9/1/2026	Updated non-preferred products.
Exdensur (J2361)	Revised	9/1/2026	Updated non-preferred products.
Nufymco (Q5168)	Revised	9/1/2026	Updated non-preferred products.
Eydenzelt (Q5170)	Revised	9/1/2026	Updated non-preferred products.
Kyxata (J9278)	New	10/1/2026	Added to step therapy policy. Require Trial/Failure Carboplatin (J9045).
Avgemsi (J9184)	New	10/1/2026	Added to step therapy policy. Require Trial/Failure Gemcitabine (J9196).
Inlexzo (J9183)	New	10/1/2026	Added to step therapy policy. Require Trial/Failure Gemcitabine (J9196).
Fulphila (Q5108)	Revised	10/1/2026	Moved to step therapy preferred alternative list.
Neulasta (J2506)	Revised	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.

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Administrative bulletin: 2026-08-002 Medicare Only

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Professional and facility Providers

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

Prime Therapeutics Medicare Advantage (Step therapy)

Drug name/Code

Action

Effective date

Change/Update