CurrentBaylor Scott & White Health PlanPolicy 307

MEDICAL COVERAGE POLICY

Defines step therapy requirements for Medicare Part B outpatient drugs and certain devices: lists drug/device classes with preferred and non-preferred agents, and specifies clinical criteria to consider non-preferred agents medically necessary. CMS coverage (NCD/LCD) and referenced BSWHP policies apply in addition.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMEDICAL COVERAGE POLICY

Policy CodePolicy 307

Change TypeRevised (class & agent updates)

Effective Date03/01/2026

Next Review Date02/26/2027

Key ActionProviders must obtain prior authorization per the specific drug or device policy and document trial/failure or intolerance to ALL preferred agents where applicable.

SourceLink

POLICY UPDATE CHANGES

Policy updated multiple times adding and removing drug classes and specific agents between 2023 and 2026.

MultipleDrug/device classes listed

ReferencesBSWHP policies referenced (e.g., 215, 219, 239, 310, 314, 045)

Coverage Summary

This Step Therapy Policy applies to Medicare Part B outpatient drugs and certain devices and defines requirements for preferred and non-preferred agents and products. CMS coverage policies (e.g., NCDs and LCDs) apply in addition to this policy; where no applicable Medicare coverage policy exists, the referenced Baylor Scott & White Health Plan (BSWHP) medical policies listed in the table will be applied, and then the step therapy requirements in this supplemental policy are used. The Plan’s stance is covered with criteria and the policy status is CURRENT.

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Step Therapy Medical Necessity Criteria

General Step Therapy Medical Necessity Criteria

Plan considers use of non-preferred medications medically necessary when ALL of the following are met:

ALL of the following

New start: The member is a new start (has not received the requested medication for the past 365 days)
Failure or intolerance to preferred drugs: The member has failure of an adequate trial of or clinically significant intolerance or contraindication to ALL preferred drugs that can also be used for the requested indication
Meet additional CMS or Plan criteria: The member meets additional clinical coverage criteria per CMS or Plan policy as specified in the table

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Non-preferred Device Medical Necessity Criteria

Plan considers use of non-preferred devices medically necessary when ALL of the following are met:

ALL of the following

Provider rationale: Provider submits clinical rationale for why non-preferred devices are medically necessary and preferred agents are not appropriate
Meet additional clinical coverage criteria: Member meets additional clinical coverage criteria as specified in the table below

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Provider Actions & Requirements

Prior Authorization

Prior authorization per specific drug/device policy

Providers must obtain prior authorization as indicated by the specific drug or device policy referenced; see the specific policy for appropriate drug or device.

Documentation Required

Document prior failure/intolerance to preferred agents

Provider must document adequate trial and failure or clinically significant intolerance/contraindication to ALL preferred drugs applicable to the requested indication (and clinical rationale for non-preferred devices).

Documentation Required

Follow CMS/local coverage and referenced BSWHP policies

Providers must ensure member meets additional clinical coverage criteria per CMS (NCD/LCD) or referenced Baylor Scott & White Health Plan policy (policy numbers cited throughout).

Background

Background: This supplemental step therapy policy applies to Medicare Part B outpatient drugs and certain devices. CMS Medicare coverage policies (NCDs/LCDs) apply in addition to this policy; where no applicable Medicare coverage policy exists, the referenced Baylor Scott & White Health Plan policies are applied first and then the step therapy requirements in this supplemental policy are used.

Preferred and non-preferred determinations were made based on cost and clinical appropriateness. The Plan considers non-preferred medications or devices medically necessary only when the specified step therapy criteria are met (e.g., member is a new start, has trial/failure or intolerance/contraindication to all preferred drugs for the indication, and meets additional CMS or Plan clinical coverage criteria).

Definitions

New startMember has not received the requested medication for the past 365 days.

Name	Number / Type
Glucose Monitors	LCD 33822 / LCD

Revision History

2026-02-26revision_summary

Policy updated multiple times adding and removing drug classes and specific agents between 2023 and 2026

2026-02-26update_detailLatest

Recent updates through 02/26/2026 include removal of methotrexate class; prior updates added denosumab biosimilars to Xgeva, added ophthalmic VEGF agent Pavblu, added non‑muscle invasive bladder cancer class, and other class-level changes.