See all Member DocumentsNeed Help? Call Us.
1-866-946-4458 (TTY: 711)
Go BackPart B Drug Policies
Medicare Advantage: Part B Step Therapy Requirements for ProvidersAs a healthcare provider, it is important to understand the CMS (Centers for Medicare & Medicaid Services) guidelines related to Part B Step Therapy for Medicare Advantage members. Step therapy is a key cost-control strategy that ensures members receive safe, effective, and clinically appropriate medications in a cost-efficient manner.
Under current CMS regulations, Medicare Advantage plans must implement step therapy protocols for certain Part B drugs, requiring members to try a preferred, lower-cost alternative before moving on to a higher-cost treatment option. See below for our Part B Step Therapy policy as well as specific step therapy policies per disease condition and/or drug class”
- Medicare Advantage Prior Authorization and Step Therapy for Part B Drugs
- Medicare Advantage and Part D Drug Pricing Final Rule
- Acromegaly - Long Acting
- Alpha1-Proteinase Inhibitors
- Antimetabolites
- Asthma
- Autoimmune Conditions
- Autoimmune-Infliximab
- Bevacizumab Oncology
- Bone Metastases
- Botulinum Toxins
- Breast Cancer
- Colony Stimulating Factors (CSF)-Long Acting
- Colony Stimulating Factors (CSF)-Short Acting
- Complement Inhibitors
- Erythropoiesis Stimulating Agents (ESA)
- Factor VIII products
- Gaucher's Disease
- Geographic Atrophy
- Gonadotropin Releasing Hormone (GnRH) Agonists – Prostate
- Hyaluronates
- Immune Globulins
- Intravenous (IV) Iron
- Mitotic Inhibitors
- Multiple Myeloma
- Multiple Sclerosis
- Osteoporosis
- PD1-PDL1 products Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) only
- PD1-PDL1 products Non-Small Cell Lung Cancer (NSCLC) only
- Retinal Disorders
- Rituximab products
- Trastuzumab products