Part B Step Therapy
We give you the information you need to take care of your health.
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 we cover 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 purpose 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) |
|---|---|
| Abraxane® | Paclitaxel (off-label uses only) |
| paclitaxel albumin-bound (American Regent) | Paclitaxel (off-label uses only) |
| paclitaxel albumin-bound (Teva) | Paclitaxel (off-label uses only) |
| Aloxi® | Zofran®, Kytril® |
| Alymsys® | Mvasi™, Zirabev® |
| Asceniv™ | Alyglo™, Bivigam®, Flebogamma®, Flebogamma® DIF, Gammagard Liquid®, Gammaked™, Gammaplex®, Gamunex®-C, Octagam®, Panzyga®, Privigen® |
| Avastin® | Mvasi™, Zirabev® |
| Avzivi® | Mvasi™, Zirabev® |
| bortezomib (Dr. Reddy’s) | Velcade®, generic bortezomib |
| bortezomib (Fresenius) | Velcade®, generic bortezomib |
| bortezomib (Hospira) | Velcade®, generic bortezomib |
| bortezomib (Maia Pharma) | Velcade®, generic bortezomib |
| Elelyso® | Cerezyme®, Cerdelga® |
| Epogen®/Procrit® | Biosimilar epoetin alfa (Retacrit)® |
| Fulphila® | Neulasta®/Neulasta® Onpro®, Udenyca®/Udenyca On-body™ |
| Fusilev® | leucovorin |
| Fylnetra® | Neulasta®/Neulasta® Onpro®, Udenyca®/Udenyca On-body™ |
| Gel-One® | Orthovisc®, Monovisc®, Euflexxa® |
| GelSyn-3® | Orthovisc®, Monovisc®, Euflexxa® |
| GenVisc® 850 | Orthovisc®, Monovisc®, Euflexxa® |
| Herceptin® | Kanjinti™, Trazimera™ |
| Herzuma® | Kanjinti™, Trazimera™ |
| Hyalgan® | Orthovisc®, Monovisc®, Euflexxa® |
| Hymovis® | Orthovisc®, Monovisc®, Euflexxa® |
| Khapzory™ | leucovorin |
| Infugem™ | gemcitabine |
| Lemtrada® | Avonex®, Rebif®, Betaseron®, Extavia®, Copaxone®, Ocrevus®, Tecfidera®, Gilenya®, Aubagio® |
| Marqibo® | vincristine sulfate |
| Neupogen® | Granix®, Zarxio® |
| Nivestym® | Granix®, Zarxio® |
| Nyvepria™ | Neulasta®/Neulasta® Onpro®, Udenyca®/Udenyca On-body™ |
| Ogivri® | Kanjinti™, Trazimera™ |
| Ontruzant® | Kanjinti™, Trazimera™ |
| Pemfexy® | Alimta®, pemetrexed (Accord), pemetrexed (BluePoint), pemetrexed (Eagle), pemetrexed (Hospira), pemetrexed (Sandoz), pemetrexed (Teva), pemetrexed ditromethamine (Hospira), Pemrydi RTU |
| Prolia® | Reclast® |
| Releuko® | Granix®, Zarxio® |
| Riabni® | Truxima®, Ruxience® |
| Rituxan® | Truxima®, Ruxience® |
| Rolvedon® | Neulasta®/Neulasta® Onpro®, Udenyca®/Udenyca On-body™ |
| Rystiggo® | Vyvgart® Hytrulo, Vyvgart® |
| Ryzneuta™ | Neulasta®/Neulasta® Onpro®, Udenyca®/Udenyca On-body™ |
| Soliris® | Ultomiris®, Uplizna® for NMOSD only |
| Stimufend® | Neulasta®/Neulasta® Onpro®, Udenyca®/Udenyca On-body™ |
| Supartz FX | Orthovisc®, Monovisc®, Euflexxa® |
| Sustol® |
|
| Synojoynt® | Orthovisc®, Monovisc®, Euflexxa® |
| Synvisc/Synvisc-One | Orthovisc®, Monovisc®, Euflexxa® |
| Treanda® | Bendeka®, Belrapzo™ |
| Triluron® | Orthovisc®, Monovisc®, Euflexxa® |
| TriVisc® | Orthovisc®, Monovisc®, Euflexxa® |
| Durolane® | Orthovisc®, Monovisc®, Euflexxa® |
| Tysabri® |
|
| Ultomiris® | Vyvgart® Hytrulo, Vyvgart® (step requirement for Generalized Myasthenia Gravis) |
| Vegzelma | Mvasi™, Zirabev® |
| Visco-3™ | Orthovisc®, Monovisc®, Euflexxa® |
| Vivimusta | Bendeka®, Belrapzo™ |
| bendamustine (Apotex) | Bendeka®, Belrapzo™ |
| bendamustine (Baxter) | Bendeka®, Belrapzo™ |
| Vpriv® | Cerezyme®, Cerdelga® |
| Xgeva® | Zometa® |
| Ziextenzo® | Neulasta®/Neulasta® Onpro®, Udenyca®/Udenyca On-body™ |
Recent/Upcoming Changes
- The following will be removed from this program effective March 15, 2024: Abraxane®; paclitaxel-albumin bound (American Regent); paclitaxel-albumin bound (Teva); Marqibo®.
- Avzivi is effective February 9, 2024 as part of this program.
- Ryzneuta is effective February 9, 2024 as part of this program.
- Fulfphila is effective January 1, 2024 as part of this program.
- Durolane, Gel-One, GelSyn-3, GenVisc 850, Hyalgan, Hymovis, Supartz FX, Synojoynt, Synvisc/Synvisc-One, Triluron, TriVisc, and Visco-3 are effective January 1, 2024 as part of this program.
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 |
| Alymsys | Alymsys is prescribed to treat certain ophthalmic conditions |
| Avastin | Avastin is prescribed to treat certain ophthalmic conditions |
| Riabni | Riabni prescribed to treat certain autoimmune diseases |
| 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 our administrative policy, Medicare Part B Utilization Management in the Absence of NCD or LCD and to review those guidelines with you as necessary and appropriate.
This content was last revised on February 12, 2024 and may be subject to change.