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|
||January 1, 2021|
|Treanda®||Bendeka®, Belrapzo™||January 1, 2021|
||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.