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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, we 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 | Requested (non-preferred) medical injectable drug | Preferred medical injectable drug | Drug Class Effective Date |
|---|---|---|---|
| Alkalyting Agent |
J9033 | Treanda® J9056 | Vivimusta |
J9034 | Bendeka® J9036 | Belrapzo® |
3/1/2023 |
| Antimetabolite Agents |
J9292 | Axtle J9304 | Pemfexy J9324 | Pemrydi |
J9304 | Alimta J9314, J9294, J9296, J9297, J9322, J9323 | Pemetrexed |
12/1/2026 |
| Blood Modifier/ Colony Stimulating Factors |
J1449 | Rolvedon® J2506 | Neulasta® J9361 | Ryzneuta Q5120 | Ziextenzo® Q5122 | Nyvepria™ Q5127 | Stimufend® Q5130 | Fylnetra® Q5169 | Armlupeg |
Q5108 | Fulphila® Q5111 | Udenyca® |
3/1/2023 |
|
J1442 | Neupogen® Q5125 | Releuko™ Q5148 | Nypozi biosimilar |
J1447 | Granix® Q5101 | Zarxio® Q5110 | Nivestym® |
5/1/2021 | |
| Bone-Modifying Agents |
J0897 | Prolia J0897 | Xgeva Q5157 | Stoboclo Q515 | Osenvelt Q5159 | Xbryk Q5159 | Ospomyv Q5158 | Bomyntra Q5158 | Conexxence Q5136 | Jubbonti Qt136 | Wyost J3590 | Boncresa J3590 | Oziltus J3590 | Oxvyrti J3590 | Jubereq |
J3489 | Zolendronic Acid 1st line followed by: Q5162 | Bildyos or Q5162 | Bilprevda or Q5167 | Enoby or Q5167 | Xtrenbo |
1/1/2027 |
| Complement Inhibitor |
J1299 | Soliris® Q5151 | Epysqli Q5152 | Bkemv |
J1303 | Ultomiris® |
3/1/2023 |
| Disease Modifying Agents / Autoinflammatory Conditions |
J3262 | Actemra Q5133 | Tofidence |
Q5135 | Tyenne Q5156 | Avtozma |
1/1/2027 |
| Folic Acid Analog |
J0641 | Fusilev® J0642 | Khapzory™ |
J0640 | leucovorin |
3/1/2023 |
| Immunosuppressants (TNF inhibitor) |
Q5104 | Renflexis® Q5121 | Avsola™ |
J1745 | Remicade® Q5103 | Inflectra® J1745 | Unbranded Infliximab |
3/1/2023 |
| Iron Replacement Product |
J1437 | Monoferric® J1439 | Injectafer® Q0138 | Feraheme® |
J1750 | INFeD® J1756 | Venofer® J2916 | Ferrlecit® |
3/1/2023 |
| Mononclonal Antibodies |
J9035 | Avastin® (oncology) Q5126 | Alymsys® Q5129 | Vegzelma® Q5160 | Jobevne J9999 | Avzivi |
Q5107 | Mvasi® Q5118 | Zirabev® |
3/1/2023 |
|
J9355 | Herceptin® J9356 | Herceptin Hylecta™ Q5112 | Ontruzant® Q5113 | Herzuma® Q5114 | Ogivri® Q5146 | Hercessi biosimilar |
Q5117 | Kanjinti® Q5116 | Trazimera® |
3/1/2023 | |
|
J9311 | Rituxan Hycela® J9312 | Rituxan™ Q5123 | Riabni® |
Q5115 | Truxima® Q5119 | Ruxience® |
3/1/2023 | |
| Nucloside metabolic Inhibitor |
J9183 | Inlexzo J9184 | Avgemsi |
J9196 | Gemcitabine |
10/1/2026 |
| Ocular Angiogenesis Inhibitors |
J0178 | Eylea® J0179 | Beovu® J2778 | Lucentis® Q5124 | Byooviz™ Q5128 | Cimerli™ J2779 | Susvimo J0177 | Eylea HD J2777 | Vabysmo Q5155 | Yesafili Q5153 | Opuviz Q5150 | Ahzantive Q5147 | Pavblu Q5149 | Enzeevu Q5168 | Nufymco Q5170 | Exdenzelt |
J9035 | C9257 | Avastin® |
1/1/2022 |
| Platinum Compound Alkylating Agent |
J9278 | Kyxata |
J9045 Carboplatin |
10/1/2026 |
| Proteosome Inhibitors |
J9049 | Bortezomib J9051 | Bortezomib J9054 | Boruzu |
J9041 | Velcade |
12/1/2026 |
| Respiratory Tract Agents |
J2786 | Cinqair J2361 | Exdensur |
J0517 | Fasenra J2182 | Nucala |
7/1/2025 |
| Systemic Lupus Erthematosus |
J0491 | Saphnelo IV |
J0490 | Benlysta |
1/1/2027 |
| Viscosupplements |
J7318 | Durolane® J7320 | Genvisc 850® J7321 | Hyalgan/Supartz/Visco-3® J7322 | Hymovis® J7324 | Orthovisc® J7326 | Gel-One® J7327 | Monovisc® J7328 | Gelsyn-3® J7329 | Trivisc™ J7331 | Synojoynt™ J7332 | Triluron® |
J7323 | Euflexxa® AND J7325 | Synvisc® OR J7325 | Synvisc-One® |
3/1/2023 |
Refer to CMS.gov for additional information
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Updated October 1, 2026
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