Soliris, Ultomiris to require step therapy for commercial members

For dates of service on or after July 22, 2024, members must try and fail — or have a contraindication or intolerance for — Empaveli^® (pegcetacoplan), HCPCS code J3590, before we’ll approve prior authorization requests for the following drugs:

• Soliris (eculizumab), HCPCS code J1300
• Ultomiris (ravulizumab), HCPCS code J1303

This step therapy requirement applies to most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members and is in addition to the other requirements that currently apply to Soliris and Ultomiris.

Prior authorization information:

• When you submit prior authorization requests for Soliris and Ultomiris, the NovoLogix^® online tool will prompt you to answer questions related to the step therapy requirement.
• Prior authorization is also required for Empaveli.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans don’t participate in the standard prior authorization program.