Pemfexy and Pemrydi RTU to have additional step therapy requirements for most members

Members must try and fail two other pemetrexed drugs before we’ll approve prior authorization requests for Pemfexy^® or Pemrydi RTU^®. For the details, refer to this table:

The preferred products are:

• Alimta^® (pemetrexed), HCPCS code J9305
• Pemetrexed (generic, various brands), HCPCS codes J9294, J9296, J9297, J9314, J9322 and J9323
• Pemrydi RTU, for dates of service from April 26 through July 31, 2024. For dates of service on or after Aug. 1, Pemrydi RTU will no longer be a preferred product, as indicated in the table above.

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

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

Members affected by this change

This requirement applies to the following members:

• 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 Carelon medical oncology 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^®.

• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

More about the prior authorization requirements

For additional information on requirements related to drugs covered under the medical benefit, refer to the following drug 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

As a reminder, prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

*Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

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.