Part B Step Therapy Drug List

The Centers for Medicare and Medicaid Services (CMS) now allows Medicare Advantage (MA) plans to apply step therapy for physician-administered and other Part B drugs. In this guidance, CMS is acknowledging that the use of step therapy is a recognized utilization management tool. The allowance of step therapy practices for Part B drugs will help achieve the goal of lower drug prices while maintaining access to covered services and drugs for beneficiaries.

As a result of this recent change, Vibra Health Plan will require review of some Part B drugs for step therapy requirements. These new Step therapy prior authorization requirements will not apply to members who are currently and actively receiving medications (members with a paid claim within the past 365 days) on the list. This will only apply to members that are “new” to the drug(s) listed below.

We will require step therapy prior authorization for the following Part B medications:

Step Therapy Drug Class Drug Name HCPCS Effective Date
Blood Modifier Agent/Colony Stimulating Factors Neupogen J1442 5/1/2021
Ocular Angiogenesis Inhibitors Bevacizumab HCPCS J3590 1/1/2022

Please refer to CMS.gov for additional information

Updated October 1, 2021
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