Part B Step Therapy Drug List

Effective May 1, 2021

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, effective May 1, 2021 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.

For dates of service on or after May 1, 2021 we will require step therapy prior authorization for the following Part B medications:

Step Therapy Drug Class Drug Name HCPCS
Blood Modifier Agent/Colony Stimulating Factors Neupogen J1442

Please refer to CMS.gov for additional information

Updated October 1, 2021
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