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 Health 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.