Pemfexy to have step therapy requirements starting in April

Members must try and fail two other pemetrexed drugs before we’ll approve prior authorization requests for Pemfexy^® (pemetrexed), HCPCS code J9304, for dates of service on or after April 26, 2024.

Members must try and fail two of the following drugs:

• Alimta^® (pemetrexed), HCPCS code J9305
• Pemrydi^® RTU (pemetrexed), HCPCS code J9324
• Pemetrexed (generic, various brands), HCPCS codes J9294, J9296, J9297, J9314, J9322, J9323

These drugs are covered under the members’ medical benefits, not their pharmacy benefits.

All of the drugs listed above continue to require prior authorization through Carelon Medical Benefits Management, as specified in the pertinent drug lists, which are linked below. We’ll update these lists to reflect the new step therapy requirement prior to the effective date.

Prior authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Members affected by this change

This new requirement applies to:

• Blue Cross Blue Shield of Michigan commercial:
• All fully insured members (group and individual)
• Members who have coverage through self-funded groups that have opted in to the Oncology value management program. This includes members who have UAW Retiree Medical Benefits Trust non-Medicare plans.
  
  Note: This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.
• Blue Care Network commercial members
• Medicare Plus Blue℠ members
• BCN Advantage℠ members

More about the prior authorization requirements
For a full list of requirements related to drugs covered under the medical benefit, see the following lists:

• Blue Cross commercial and BCN commercial:
• Oncology value management prior authorization list for Blue Cross and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• Oncology value management program prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue℠ and BCN Advantage℠ members

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.