Web Content Viewer - Metadata
Breadcrumb DnD
Plain Page with Image DnD
Part B Step Therapy Drug List
The Centers for Medicare and Medicaid Services (CMS) now allows Medicare Advantage (MA) plans to apply step therapy for physician-administered and other Part B drugs. In this guidance, CMS is acknowledging that the use of step therapy is a recognized utilization management tool. The allowance of step therapy practices for Part B drugs will help achieve the goal of lower drug prices while maintaining access to covered services and drugs for beneficiaries.
As a result of this recent change, we will require review of some Part B drugs for step therapy requirements. These new Step therapy prior authorization requirements will not apply to members who are currently and actively receiving medications (members with a paid claim within the past 365 days) on the list. This will only apply to members that are “new” to the drug(s) listed below.
We will require step therapy prior authorization for the following Part B medications:
| Step Therapy Drug Class | Requested (non-preferred) medical injectable drug | Preferred medical injectable drug | Drug Class Effective Date |
|---|---|---|---|
| Alkalyting Agent | J9033 | Treanda® |
J9034 | Bendeka® J9036 | Belrapzo® |
3/1/2023 |
| Blood Modifier/ Colony Stimulating Factors |
J1449 | Rolvedon® Q5108 | Fulphila® Q5120 | Ziextenzo® Q5122 | Nyvepria™ Q5127 | Stimufend® Q5130 | Fylnetra® |
J2506 | Neulasta® Q5111 | Udenyca® |
3/1/2023 |
|
J1442 | Neupogen® Q5125 | Releuko™ |
J1447 | Granix® Q5101 | Zarxio® Q5110 | Nivestym® |
5/1/2021 | |
| Complement Inhibitor | J1299 | Soliris® (PNH, aHUS use) | J1303 | Ultomiris® | 3/1/2023 |
| Folic Acid Analog |
J0641 | Fusilev® J0642 | Khapzory™ |
J0640 | leucovorin | 3/1/2023 |
| Immunosuppressants (TNF inhibitor) |
Q5104 | Renflexis® Q5121 | Avsola™ |
J1745 | Remicade® Q5103 | Inflectra® Unbranded Infliximab |
3/1/2023 |
| Iron Replacement Product |
J1437 | Monoferric® J1439 | Injectafer® Q0138 | Feraheme® |
J1750 | INFeD® J1756 | Venofer® J2916 | Ferrlecit® |
3/1/2023 |
| Mononclonal Antibodies |
J9035 | Avastin® (oncology) Q5126 | Alymsys® Q5129 | Vegzelma® |
Q5107 | Mvasi® Q5118 | Zirabev® |
3/1/2023 |
|
J9355 | Herceptin® J9356 | Herceptin Hylecta™ Q5112 | Ontruzant® Q5113 | Herzuma® Q5114 | Ogivri® |
Q5117 | Kanjinti® Q5116 | Trazimera® |
3/1/2023 | |
|
J9311 | Rituxan Hycela® J9312 | Rituxan™ Q5123 | Riabni® |
Q5115 | Truxima® Q5119 | Ruxience® |
3/1/2023 | |
| Ocular Angiogenesis Inhibitors Temporary lift on the non-preferred requirement due to Avastin shortage per CMS memo 11/25/2024 |
J0178 | Eylea® J0179 | Beovu® J2778 | Lucentis® Q5124 | Byooviz™ Q5128 | Cimerli™ |
J9035 | Avastin® | 1/1/2022 |
| Viscosupplement |
J7318 | Durolane® J7320 | Genvisc 850® J7321 | Hyalgan/Supartz/Visco-3® J7322 | Hymovis® J7324 | Orthovisc® J7326 | Gel-One® J7327 | Monovisc® J7328 | Gelsyn-3® J7329 | Trivisc™ J7331 | Synojoynt™ J7332 | Triluron® |
J7323 | Euflexxa® J7325 | Synvisc® J7325 | Synvisc-One® |
3/1/2023 |
Refer to CMS.gov for additional information
Web Content Viewer - Fixed Context
Updated January 1, 2025
Y0016_25WBST_M