Step Therapy for Part B Drugs
Some Part B drugs may require step therapy.Â
Drugs that are injected or infused by your physician in their office, or in a hospital outpatient or ambulatory surgical center, are typically covered under your medical (Part B) benefit. Some Part B drugs may require step therapy. Step therapy means that a preferred drug must be tried before a non-preferred drug will be approved by your plan. If you have already been on a non-preferred drug in the previous 365 days, you may continue using the non-preferred drug.Â
In Scope Drug Category | Non-Preferred Drug Products | Preferred Drug Products |
Anemia (intravenous iron replacement) | Feraheme Injectafer Monoferric | Ferrlecit INFed Venofer |
Anti-Nausea Products for Oncology (specifically when used as part of a chemotherapy regimen) | Akynzeo Cinvanti Sustol | Aloxi Emend* Granisetron (Kytril) Ondansetron (Zofran) |
Bevacizumab Products (for cancer conditions only) | Alymsys Avastin | Mvasi* Zirabev* |
Bone Density Agents for Oncology | Prolia Xgeva | Ibandronate Pamidronate Zoledronic Acid |
Bone Density Agents for Osteoporosis | Evenity Prolia | Alendronate Ibandronate Risedronate Pamidronate Zoledronic Acid |
Gemcitabine | Infugem (J9198) | Gemcitabine (J9201)* |
Gonadotropin Releasing Hormone Analogs for Oncology | Leuprolide Acetate 3.75 mg (J1950) | Leuprolide Acetate 7.5 mg (J9217)* |
Gout Agents | Krystexxa | Allopurinol Febuxostat |
Immune Globulins | Asceniv Cutaquig Panzyga | Bivigam* Carimune NF* Cuvitru* Flebogamma DIF* Gammagard Liquid* Gammagard S/D* Gammaked* Gammaplex* Gamunex-C* Hizentra* HyQvia* Octagam* Privigen* Xembify* |
Inflammatory Conditions (such as Rheumatoid Arthritis) | Infliximab Remicade Renflexis | Inflectra Avsola |
Leucovorin/Levoleucovorin | Fusilev Khapzory Levoleucovorin | Leucovorin* |
Lupus Agents | Saphnelo | Benlysta |
Nebulizer Solutions (dispensed at a pharmacy) | Brovana | Perforomist |
Orthopedic Joint Lubricant (Medical Device) | Euflexxa Gel-One Genvisc 850 Hyalgan Supartz Supartz FX Synojoynt Triluron TriVisc Visco-3 | Durolane Gelsyn-3 Synvisc/Synvisc-One |
Red Blood Cell Generation | Epogen Procrit | Retacrit |
Rituximab Products (for both cancer and non-cancer conditions) | Riabni Rituxan Rituxan Hycela | Ruxience* Truxima* |
Trastuzumab Products | Herceptin Herceptin Hylecta Herzuma Ogivri Ontruzant | Kanjinti* Trazimera* |
Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Age Related Macular Degeneration) | Beovu Byooviz Lucentis Susvimo Vabysmo | First: Compounded Avastin (bevacizumab) Then: Eylea |
Vascular Endothelial Growth Factor (VEGF) Inhibitors (for conditions other than Age Related Macular Degeneration) | Beovu Byooviz Lucentis Susvimo Vabysmo | Eylea |
White Blood Cell Generation (Short Acting) | Granix Neupogen Nivestym Relueko | Zarxio* |
White Blood Cell Generation (Long Acting) | Fulphilia Fylnetra Udenyca Nyvepria | Neulasta* Ziextenzo* |
*No prior authorization is required for Preferred Drug Products with the following exceptions: 1. Drug is used for a cancer diagnosis 2. Drug is an Immune Globulin |
Only certain plans will require step therapy for these Part B drugs. If you are using one of these drugs under the Part B benefit, please contact the customer service center at the phone number on the back of your ID card to determine if your plan is in scope.