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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 Class Drug Name Status Billing Code
Bone resorption inhibitors Pamidronate Preferred J2430
Zoledronic acid Preferred J3489
Xgeva Non-preferred J0897
Colony Stimulating Factors -Leukocyte Growth Factors (long-acting) Fulphila Preferred Q5108
Neulasta / Neulasta Onpro Non-Preferred J2505
Udenyca Preferred Q5111
Ziextenzo Preferred C9399, J3590
Colony-stimulating factors leukocyte growth factors (short-acting) Neupogen Non-Preferred J1442
Nivestym Preferred Q5110
Granix Preferred J1447
Zarxio Preferred Q5101
COPD Perforomist Preferred J7606
Brovana Non-preferred J7605
Doxorubicin (liposomal) Doxorubicin conventional Preferred J9000
Epirubicin Preferred J9178
Doxil Non-preferred Q2050
Erythropoiesis-stimulating agents Retacrit Preferred Q5106
Aranesp Preferred J0881
Epogen Non-preferred J0885
Mircera Non-preferred J0888
Procrit Non-preferred J0885
Gaucher’s disease Cerdelga Preferred J8499
Cerezyme Preferred J1786
Elelyso Preferred J3060
Vpriv Non-preferred J3385
Zavesca Non-preferred J8499
Hemophilia A Advate Preferred J7192
Adynovate Preferred J7207
Afstyla Preferred J7210
Eloctate Preferred J7205
Helixate FS Preferred J7192
Hemofil-M Preferred J7190
Jivi Preferred J7208
Koate-DVI Preferred J7190
Kogenate FS Preferred J7192
Kovaltry Preferred J7211
Monoclate-P Preferred J7190
NovoEight Preferred J7182
Nuwiq Preferred J7209
Hemophilia A (continued) Recombinate Preferred J7192
Xyntha Preferred J7185
Hemlibra Non-preferred J7170
Hereditary angioedema acute use Ruconest Preferred J0596
Berinert Non-preferred J0597
Firazyr Non-preferred J1744
icatibant Non-preferred J1744
Kalbitor Non-preferred J1290
Hereditary angioedema prophylaxis Haegarda Preferred J0599
Cinryze Non-preferred J0598
Takhzyro Non-preferred J0593
Immunologic drugs autoimmune disorders (arthritis, psoriasis, inflammatory bowel disease) Inflectra Preferred Q5103
Remicade Non-Preferred J1745
Simponi Aria Preferred J1602
Stelara Preferred J3358
Actemra IV Non-preferred J3262
Entyvio Non-preferred J3380
Ilumya Non-preferred J3245
Orencia IV Non-preferred J0129
Renflexis Preferred Q5104
Rituxan IV Non-preferred J9312
Tysabri Non-preferred J2323
Myelodysplastic syndrome Azacitidine Preferred J9025
Dacogen Non-preferred J0894
Decitabine Non-preferred J0894
Neoplasms (excluding pancreatic) Docetaxel Preferred J9171
Paclitaxel Preferred J9267
Abraxane Non-preferred J9264
Ophthalmic disorders Avastin Preferred C9257, J9035
Beovu Non-preferred J0179
Eylea Non-preferred J0178
Lucentis Non-preferred J2778
Macugen Non-preferred J2503
Visudyne Non-preferred J3396
Osteoporosis Zoledronic acid Preferred J3489
Prolia Non-preferred J0897
Rituximab and hyaluronidase Rituxan IV Preferred J9312
Rituxan Hycela Non-preferred J9311
Somatostatin analogs (Lutathera) Sandostatin LAR Preferred J2353
Somatuline Depot Preferred J1930
Lutathera Non-preferred A9513
Somatostatin analogs (Signifor LAR) Octreotide acetate Preferred J2354
Sandostatin Preferred J2354
Signifor LAR Non-preferred J2502
Trastuzumab and hyaluronidase – oysk Herceptin (IV) Preferred J9355
Herzuma Preferred Q5113
Kanjinti Preferred Q5117
Ogivri Preferred Q5114
Ontruzant Preferred Q5112
Trazimera Preferred Q5116
Herceptin Hylecta Non-preferred J9356
Vincristine (liposomal) Vincristine sulfate Preferred J9370
Marqibo Non-preferred J9371
Viscosupplements Monovisc Preferred J7327
Orthovisc Preferred J7324
Durolane Non-preferred J7318
Euflexxa Preferred J7323
Gel-One Non-preferred J7326
Gelsyn-3 Non-preferred J7328
GenVisc 850 Non-preferred J7320
Hyalgan Non-preferred J7321
Hymovis Non-preferred J7322
Sodium Hyaluronate Non-preferred C9399, J3490
Supartz FX Non-preferred J7321
Synvisc Non-preferred J7325
Synvisc One Non-preferred J7325
Triluron Non-preferred J7332
TriVisc Non-preferred J7329
Visco-3 Non-preferred J7321

 

Revised April 2020.

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