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Step Therapy for Provider Administered Medication

In August 2018, the Centers for Medicare & Medicaid Services (CMS) issued a ruling that allowed Medicare Advantage plans to apply step therapy edits to Part B drugs, which may be more costly, but may not be more effective.

This ruling states that certain “preferred” medications must be tried before using “non-preferred” medications for certain conditions. Or, there must be a valid medical reason not to try the “preferred” medication first.

Affected drugs are noted below.

If providers do not stock our preferred drug in their office, they may be able to obtain the preferred drug from a pharmacy (i.e., a pharmacy can ship the medication to the office).

This step therapy requirement will not apply to patients who are already actively receiving treatment with a “non-preferred” drug (have a paid drug claim within the past 365 days).

Intermountain Healthcare Medicare Advantage patients subject to the step therapy requirement may:

  • Request expedited exception reviews for step therapy prior authorization requests.
  • Appeal a denied request for a “Non-preferred” drug due to step therapy requirements
Drug ClassDrug NameStatusBilling Code
Bone resorption inhibitorsPamidronatePreferredJ2430
Zoledronic acidPreferredJ3489
XgevaNon-preferredJ0897
Colony Stimulating Factors -Leukocyte Growth Factors (long-acting)FulphilaPreferredQ5108
Neulasta / Neulasta OnproNon-PreferredJ2505
UdenycaPreferredQ5111
ZiextenzoPreferredC9399, J3590
Colony-stimulating factors leukocyte growth factors (short-acting)NeupogenNon-PreferredJ1442
NivestymPreferredQ5110
GranixPreferredJ1447
ZarxioPreferredQ5101
COPDPerforomistPreferredJ7606
BrovanaNon-preferredJ7605
Doxorubicin (liposomal)Doxorubicin conventionalPreferredJ9000
EpirubicinPreferredJ9178
DoxilNon-preferredQ2050
Erythropoiesis-stimulating agentsRetacritPreferredQ5106
AranespPreferredJ0881
EpogenNon-preferredJ0885
MirceraNon-preferredJ0888
ProcritNon-preferredJ0885
Gaucher’s diseaseCerdelgaPreferredJ8499
CerezymePreferredJ1786
ElelysoPreferredJ3060
VprivNon-preferredJ3385
ZavescaNon-preferredJ8499
Hemophilia AAdvatePreferredJ7192
AdynovatePreferredJ7207
AfstylaPreferredJ7210
EloctatePreferredJ7205
Helixate FSPreferredJ7192
Hemofil-MPreferredJ7190
JiviPreferredJ7208
Koate-DVIPreferredJ7190
Kogenate FSPreferredJ7192
KovaltryPreferredJ7211
Monoclate-PPreferredJ7190
NovoEightPreferredJ7182
NuwiqPreferredJ7209
Hemophilia A (continued)RecombinatePreferredJ7192
XynthaPreferredJ7185
HemlibraNon-preferredJ7170
Hereditary angioedema acute useRuconestPreferredJ0596
BerinertNon-preferredJ0597
FirazyrNon-preferredJ1744
icatibantNon-preferredJ1744
KalbitorNon-preferredJ1290
Hereditary angioedema prophylaxisHaegardaPreferredJ0599
CinryzeNon-preferredJ0598
TakhzyroNon-preferredJ0593
Immunologic drugs autoimmune disorders (arthritis, psoriasis, inflammatory bowel disease)InflectraPreferredQ5103
RemicadeNon-PreferredJ1745
Simponi AriaPreferredJ1602
StelaraPreferredJ3358
Actemra IVNon-preferredJ3262
EntyvioNon-preferredJ3380
IlumyaNon-preferredJ3245
Orencia IVNon-preferredJ0129
RenflexisPreferredQ5104
Rituxan IVNon-preferredJ9312
TysabriNon-preferredJ2323
Myelodysplastic syndromeAzacitidinePreferredJ9025
DacogenNon-preferredJ0894
DecitabineNon-preferredJ0894
Neoplasms (excluding pancreatic)DocetaxelPreferredJ9171
PaclitaxelPreferredJ9267
AbraxaneNon-preferredJ9264
Ophthalmic disordersAvastinPreferredC9257, J9035
BeovuNon-preferredJ0179
EyleaNon-preferredJ0178
LucentisNon-preferredJ2778
MacugenNon-preferredJ2503
VisudyneNon-preferredJ3396
OsteoporosisZoledronic acidPreferredJ3489
ProliaNon-preferredJ0897
Rituximab and hyaluronidaseRituxan IVPreferredJ9312
Rituxan HycelaNon-preferredJ9311
Somatostatin analogs (Lutathera)Sandostatin LARPreferredJ2353
Somatuline DepotPreferredJ1930
LutatheraNon-preferredA9513
Somatostatin analogs (Signifor LAR)Octreotide acetatePreferredJ2354
SandostatinPreferredJ2354
Signifor LARNon-preferredJ2502
Trastuzumab and hyaluronidase – oyskHerceptin (IV)PreferredJ9355
HerzumaPreferredQ5113
KanjintiPreferredQ5117
OgivriPreferredQ5114
OntruzantPreferredQ5112
TrazimeraPreferredQ5116
Herceptin HylectaNon-preferredJ9356
Vincristine (liposomal)Vincristine sulfatePreferredJ9370
MarqiboNon-preferredJ9371
ViscosupplementsMonoviscPreferredJ7327
OrthoviscPreferredJ7324
DurolaneNon-preferredJ7318
EuflexxaPreferredJ7323
Gel-OneNon-preferredJ7326
Gelsyn-3Non-preferredJ7328
GenVisc 850Non-preferredJ7320
HyalganNon-preferredJ7321
HymovisNon-preferredJ7322
Sodium HyaluronateNon-preferredC9399, J3490
Supartz FXNon-preferredJ7321
SynviscNon-preferredJ7325
Synvisc OneNon-preferredJ7325
TriluronNon-preferredJ7332
TriViscNon-preferredJ7329
Visco-3Non-preferredJ7321

 

Revised April 2020.

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