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Part B Step Therapy

With Medicare Advantage plans, some Part B drugs have certain requirements or coverage limits, such as step therapy. Our Part B Step Therapy Program encourages you to try less costly, but just as effective, preferred alternative Part B drugs before the plan covers another drug prescribed by your doctor.

How Part B Step Therapy works

If your doctor prescribes a new drug for you that is listed in the Requested Product column of the table below to treat your medical condition, we may first require you to try one of the drugs included in the Preferred Alternative Agent(s) column. If the Preferred Alternative Agent does not work for you, then we will cover the Requested Product if it meets the medical necessity criteria outlined in our medical policy guidelines. For the purposes of this program, a “new” drug is one that you have not taken for at least 365 days prior to a particular prescription.

If you have questions, please talk to your doctor about this program. Your doctor can access our medical policy guidelines pertaining to a specific drug and then review those guidelines with you.

Requested Product Preferred Alternative Agent(s) Included in the program beginning
Abraxane® Paclitaxel (off-label uses only) January 1, 2021
Aloxi Zofran, Kytril January 1, 2021
Asceniv™ Bivigam®, Carimune® NF, Flebogamma®, Flebogamma® DIF, Gammagard Liquid®, Gammaked™, Gammaplex®, Gamunex®-C, Octagam®, Panzyga®, Privigen® January 1, 2022
Avastin® Mvasi™, Zirabev® January 1, 2021
Elelyso Cerezyme, Cerdelga January 1, 2021
Epogen/Procrit Biosimilar epoetin alfa (Retacrit) January 1, 2021
Fusilev®, Khapzory™ leucovorin January 1, 2021
Herceptin® Kanjinti™, Trazimera™ January 1, 2021
Herzuma® Kanjinti™, Trazimera™ January 1, 2021
Infugem™ gemcitabine January 1, 2021
Lemtrada Avonex, Rebif, Betaseron, Extavia, Tysabri, Copaxone, Tysabri, Ocrevus, Tecfidera, Gilenya, Aubagio January 1, 2021
Marqibo® vincristine sulfate October 15, 2021
Neupogen Granix, Zarxio January 1, 2021
Nivestym® Granix, Zarxio January 1, 2021
Nyvepria Neulasta®, Fulphila®, Udencya® January 1, 2021
Ogivri® Kanjinti™, Trazimera™ April 29, 2022
Ontruzant® Kanjinti™, Trazimera™ January 1, 2021
Prolia Reclast January 1, 2021
Releuko Granix, Zarxio May 13, 2022
Riabni® Truxima®, Ruxience® April 9, 2021
Rituxan® Truxima®, Ruxience® January 1, 2021
Soliris® Ultomiris® January 1, 2021
Sustol
  • For use with highly emetogenic (nausea-causing) chemotherapy agents: Aloxi
  • For moderately emetogenic (nausea-causing) chemotherapy agents: Zofran, Kytril
January 1, 2021
Treanda® Bendeka®, Belrapzo™ January 1, 2021
Tysabri
  • For Multiple Sclerosis: Interferon beta (i.e. Avonoex, Rebif, Betaseron, Extavia), Copaxone
  • For Crohn’s Disease: Immunosuppressants (5-ASA, 6-mercaptopurine, azathioprine, cyclosporine, methotrexate), TNF Antagonist
January 1, 2021
Vpriv Cerezyme, Cerdelga January 1, 2021
Xgeva Zometa January 1, 2021
Ziextenzo® Neulasta®, Fulphila®, Udencya® January 1, 2021

Step Therapy Program Exceptions

When the Requested Products in the table below are prescribed to treat certain specific conditions, we will not require you to first try a Preferred Alternative Agent as part of this program.

Requested Product A Preferred Alternative Agent will NOT be required when:
Aloxi Aloxi is prescribed in combination with highly emetogenic (nausea-causing) chemotherapy agents
Avastin Avastin is prescribed to treat certain ophthalmic conditions
Rituxan Rituxan is prescribed to treat certain autoimmune diseases
Soliris Soliris is prescribed to treat certain disorders of the brain and spinal cord

Your doctor may access our medical policy guidelines pertaining to the drugs listed here and review those guidelines with you.

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