CurrentAmeriHealthPolicy N/A

Medicare Part B step therapy for select drugs

Defines AmeriHealth's use of step therapy for certain Medicare Part B drugs, listing preferred and non-preferred products across multiple drug categories and who this affects (Medicare members covered by AmeriHealth).

Policy Summary

PayerAmeriHealth

PolicyMedicare Part B step therapy for select drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMembers must try a plan-identified preferred product in the indicated drug category before AmeriHealth will cover a non-preferred product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13document chunks

11drug categories listed

multiplepreferred vs non-preferred

Coverage Criteria

General Step Therapy Requirement

Covered when members have tried preferred products as required by step therapy

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Provider Actions and Requirements

Step Therapy

Overview of step therapy process

In certain drug categories where there are multiple treatment options with similar clinical results, AmeriHealth may use a step therapy process. AmeriHealth identifies preferred products within those categories; members are required to try a preferred product before AmeriHealth will cover a non-preferred Medicare Part B drug. The requirements for preferred products and level designations (e.g., Level 1 preferred, Level 2/3 non-preferred) are available in AmeriHealth medical policies and the lists are subject to change.

Members must try a preferred product (level-designated) before a non-preferred product will be covered.
Preferred products and non-preferred alternatives are listed in AmeriHealth medical policy documents and plan drug lists.

Denial Risk

Step therapy denial trigger

Coverage of a non-preferred product may be denied unless the member has first tried (and failed or had an intolerance to) a designated preferred product as required by AmeriHealth’s step therapy process.

Denial of coverage may occur if step therapy requirements are not met.
Exceptions or prior authorization may be available when medically necessary documentation supports use of a non-preferred product.

Note

Medications subject to step therapy (examples)

Preferred and non-preferred examples for ophthalmologic VEGF therapies and select oncology biologics are maintained by AmeriHealth and may change. Examples from the current list include preferred VEGF products (Level 1): Alymsys®, Avastin®, Avzivi®, Mvasi®, Vegzelma®, Zirabev®; and non-preferred VEGF products (Level 3): Ahzantive®, Beovu®, Enzeevu®, Eylea®, Eylea HD®, Eyzenvelt®, Susvimo™, Opuviz®, Vabysmo®, Yesafili®. Oncology examples include lists of preferred and non-preferred biologics.

Ophthalmologic VEGF preferred (Level 1): Alymsys®, Avastin®, Avzivi®, Mvasi®, Vegzelma®, Zirabev®.
Ophthalmologic VEGF non-preferred (Level 3): Ahzantive®, Beovu®, Enzeevu®, Eylea®, Eylea HD®, Eyzenvelt®, Susvimo™, Opuviz®, Vabysmo®, Yesafili®.
Other categories (e.g., certain oncology biologics) have preferred and non-preferred designations — see AmeriHealth medical policies for full lists.

Note

Contact for coverage details

For a complete listing of Medicare Part B drugs subject to step therapy, questions about level designations, or to request coverage details and available exceptions, providers may contact the AmeriHealth Help Team or view online resources.

Call AmeriHealth Help Team: 1-866-569-5190 (TTY/TDD: 711), 8 a.m. – 8 p.m., Monday–Friday.*
Visit: AmeriHealth.com/Medicare
*Note: On weekends and holidays from April 1 through September 30, calls may be sent to voicemail.

Definitions

Step therapy (inv-08) definition

DefinitionA utilization management process in which the health plan requires trying a preferred product first before covering a non-preferred product.

PurposeUsed when multiple treatment options have similar clinical results to promote use of preferred products first.

ApplicationMembers must try a preferred product before AmeriHealth will cover treatment with a non-preferred product.

Source of preferred listsRequirements and preferred product lists are available in AmeriHealth medical policies and are subject to change.

Preferred product (inv-09) definition

DefinitionA drug designated by the health plan as the first‑line choice within a drug category for coverage purposes (identified by AmeriHealth as a preferred product).

Role in step therapyPreferred products must be tried by members prior to coverage of non‑preferred products under AmeriHealth's step therapy process.

Where to find designationsPreferred product designations and requirements are listed in AmeriHealth medical policies and may change.

Effect on coverageCoverage of non‑preferred products may be denied unless a preferred product has been tried as required by step therapy.

Step Therapy Drug Categories and Requirements

Drug category	Preferred (plan‑identified) products	Non‑preferred products
Cancer	Eligard; Mvasi; Zirabev; Kanjinti; Ogivri; Ontruzant; Riabni; Ruxience; Truxima	Camcevi; Lupron depot; Alymsys; Avastin; Avzivi; Vegzelma; Herceptin; Hercessi; Herceptin Hylecta; Herzuma; Trazimera; Rituxan; Rituxan Hycela
Colony‑stimulating factors (long‑acting)	Fulphila; Neulasta	Fylnetra; Nyvepria; Rolvedon; Stimufend; Udenyca; Udenyca OnBody; Ziextenzo
Colony‑stimulating factors (short‑acting)	Nivestym; Zarxio	Neupogen; Granix; Releuko
Denosumab products	Jubbonti; Stoboclo; Osenvelt; Wyost	Aukelso; Bildyo; Bilprevda; Bomyntra; Bosaya; Connexence; Enoby; Ospomyv; Prolia; Xbryk; Xgeva; Xtrenbo
Eculizumab products	Epysqli	Bkemv; Soliris
Hyaluronate acid products	Monovisc; Orthovisc; Synvisc; Synvisc‑One	Durolane; Euflexxa; Gel‑One; Gelsyn3; GenVisc‑850; Hyalgan; Hymovis; Supartz; Synojoynt; Triluron; TriVisc; VISCO‑3
Infliximab products	Avsola; Inflectra; Infliximab (unbranded); Ixifi; Remicade; Renflexis
Intravenous Immune Globulin (IVIG)	Bivigam; Cutaquig; Cuvitru; Flebogamma; Flebogamma DIF; Gamastan S/D; Gammagard Liquid; Gammagard S/D; Gammaked; Gammaplex; Gamunex C; Hizentra; HyQvia; Octagam; Privigen; Xembify; Yimmugo	Alyglo; Asceniv; Panzyga
IV Iron	All generic IV iron (Feraheme; Ferrlecit; INFeD; Venofer)	Injectafer; Monoferric (Non‑preferred Level 2)
Myasthenia Gravis agents	Vyvgart; Rystiggo	Imaavy; Ultomiris; Epysqli; Soliris; Bkemv
Ophthalmologic VEGF inhibitors	Alymsys; Avastin; Avzivi; Mvasi; Vegzelma; Zirabev (Preferred Level 1)	Byooviz; Cimerli; Lucentis (Non‑preferred Level 2); Ahzantive; Beovu; Enzeevu; Eylea; Eylea HD; Eyzenvelt; Susvimo; Opuviz; Vabysmo; Yesafili (Non‑preferred Level 3)

Biosimilar and Biologic Designations

Billing Rule

Biosimilar / reference biologic preferred designations

Preferred designations exist for certain biosimilars and reference biologics by category; AmeriHealth lists preferred (Level 1) and non-preferred biologics (Levels 2 and 3) for ophthalmologic VEGF inhibitors and other categories.

Example — Ophthalmologic VEGF inhibitors: Preferred (Level 1) include Alymsys®, Avastin®, Avzivi®, Mvasi®, Vegzelma®, Zirabev®; Non-preferred include Level 2 (Byooviz™, Cimerli®, Lucentis®) and Level 3 (Ahzantive®, Beovu®, Eylea®, etc.).

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