CurrentBaylor Scott & White Health PlanPolicy N/A

Medicare Part B Step Therapy for medically administered drugs

Defines Part B step therapy requirements for certain medically administered medications (injectables/biologics) for Baylor Scott & White Health Plan Medicare members, including lists of preferred and non-preferred drugs and effective dates. Affects providers submitting Part B drug claims and prior authorization requests for these drugs.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Part B Step Therapy for medically administered drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must generally trial a preferred Part B drug for the indicated condition before coverage of a listed non-preferred Part B drug unless the member received the non-preferred drug within the past 365 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipletherapeutic categories listed

1/1/2025most entries effective

5/1/2025ophthalmic VEGF list effective

365lookback period (days)

Coverage Criteria & Eligibility

Step therapy initial coverage criteria

Covered when ALL of the following are met:

Step therapy rule set: 1) The drug is a listed Part B non-preferred agent subject to step therapy; 2) The member has not received the same non-preferred drug within the past 365 days; 3) There is no documented trial/failure or contraindication to the preferred Part B drug365 days

Prior authorization may still be required; providers must document trials of preferred agents as applicable.

Members who have received treatment with a non-preferred Part B drug within the past 365 days are exempt from the step therapy requirement. This lookback exemption means that if the member was administered the same non-preferred agent during the prior 365-day period, the requirement to first trial a preferred Part B drug does not apply.

Coding, Lookback & Definitions

Lookback period

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Part B Step Therapy for medically administered drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider Responsibilities & Authorization

Prior Authorization

Prior Authorization May Be Required

Both preferred and non-preferred Medicare Part B drugs listed may require prior authorization. Providers should verify PA requirements before ordering or administering Part B medications, as PA may be required even when step therapy is not.

Applies to all Part B drugs listed under the Step Therapy program.
Check member-specific eligibility and prior authorization rules prior to administration.

Step Therapy

Step Therapy Requirement

When step therapy applies, providers must generally trial a listed preferred Part B drug before the plan will cover a non-preferred Part B drug. The step therapy requirement does not apply if the member received the non-preferred drug within the prior 365 days.

Step therapy exceptions: prior treatment with the non-preferred drug within past 365 days removes the step requirement.
Preferred and non-preferred drug lists are updated periodically; confirm current status and effective dates.

Documentation Required

Documentation of Trials and Prior Authorization

Providers must document trials of preferred Part B drugs when submitting for coverage of a non-preferred drug. Documentation should include agents tried, dates of therapy, clinical response, and reasons for failure or intolerance. Note that prior authorization may still be required even when documentation of trials is provided.

Include dates and clinical rationale for change to non-preferred agent.
Attach prior trial documentation to the PA request to expedite review.

Denial Risk

Step Therapy Non-Compliance

Failure to complete an applicable step therapy trial (and to document any exception) may result in denial of coverage for the non-preferred Part B drug. Providers should confirm step therapy applicability and submit required documentation or exception rationale with the initial authorization request to avoid claim denials.

Denial risk increases if step therapy requirements are not met or not documented.
If denied, follow the plan’s appeals or exception process with supporting clinical evidence.

Initial Therapy Preferred Agent Preference

Initial therapy preferred agent preference

Preferred agents listed below do not require step therapy as of the effective date shown; the non-preferred lists are subject to step therapy unless the lookback exemption applies.

Trastuzumab (effective 1/1/2025): Preferred: Trazimera, Kanjinti, Ogivri, Ontruzant, Herzuma. Non-preferred (step required): Herceptin, Herceptin Hylecta.

Bevacizumab — oncology use (effective 1/1/2025): Preferred: Mvasi, Zirabev. Non-preferred (step required): Avastin, Alymsys, Avzivi, Vegzelma.

Colony Stimulating Agents — long acting (effective 1/1/2025): Preferred: Neulasta, Udenyca. Non-preferred (step required): Fulphilia, Fylnetra, Nyvepria, Stimufend, Ziextenzo.

Rituximab (effective 1/1/2025): Preferred: Ruxience, Truxima. Non-preferred (step required): Rituxan, Rituxan Hycela, Riabni.

Colony Stimulating Agents — short acting (effective 1/1/2025): Preferred: Zarxio. Non-preferred (step required): Neupogen, Nivestym, Releuko, Granix.

VEGF inhibitors — ophthalmic indications only (effective 5/1/2025): Preferred: Avastin. Non-preferred (step required): Beovu, Byooviz, Eylea, Eylea HD, Lucentis, Susvimo, Vabysmo.

Bendamustine (effective 1/1/2025): Listed agents: Belrapzo, Bendeka, Bendamustine (brand Treanda); Bendamustine 50562 formulations: Vivimusta.

Bone antiresorptive therapy — oncology use (effective 1/1/2025): Listed agents: Zoledronic acid, Xgeva. (Does not apply to prostate or breast cancer.)

Taxane therapy (effective 1/1/2025): Listed agents: Paclitaxel (Taxol), Docetaxel (Taxotere); Docetaxel 50562 formulations; Paclitaxel Protein-Bound (Abraxane) and its 50562 formulations. (Does not apply to pancreatic cancer, ampullary adenocarcinoma, biliary tract cancers.)

Step Therapy Lists & Effective Dates

Drug class / indication	Preferred Part B drug(s) (No step therapy)	Non-preferred Part B drug(s) (Step therapy required)	Effective date	Coverage
Trastuzumab	Trazimera; Kanjinti; Ogivri; Ontruzant; Herzuma	Herceptin; Herceptin Hylecta	1/1/2025	Covered with step therapy: trial of preferred agent required before non-preferred
Bevacizumab (oncology use)	Mvasi; Zirabev	Avastin; Alymsys; Avzivi; Vegzelma	1/1/2025	Covered with step therapy: trial of preferred agent required before non-preferred
Colony Stimulating Agents (long acting)	Neulasta; Udenyca	Fulphilia; Fylnetra; Nyvepria; Stimufend; Ziextenzo	1/1/2025	Covered with step therapy: trial of preferred agent required before non-preferred
Rituximab	Ruxience; Truxima	Rituxan; Rituxan Hycela; Riabni	1/1/2025	Covered with step therapy: trial of preferred agent required before non-preferred
Colony Stimulating Agents (short acting)	Zarxio	Neupogen; Nivestym; Releuko; Granix	1/1/2025	Covered with step therapy: trial of preferred agent required before non-preferred
Vascular Endothelial Growth Factor (VEGF) inhibitors — ophthalmic indications only	Avastin	Beovu; Byooviz; Eylea; Eylea HD; Lucentis; Susvimo; Vabysmo	5/1/2025	Covered with step therapy: trial of preferred agent required before non-preferred
Bendamustine	Belrapzo; Bendeka; Bendamustine (Treanda)	Bendamustine 50562 formulations; Vivimusta	1/1/2025	Covered with step therapy: trial of preferred agent required before non-preferred
Bone antiresorptive therapy (oncology use; does not apply to prostate or breast cancer)	Zoledronic acid; Xgeva		1/1/2025	Covered with step therapy where specified; trial of preferred agent required before non-preferred
Taxane therapy (excludes pancreatic, ampullary adenocarcinoma, biliary tract cancers)	Paclitaxel (Taxol); Docetaxel (Taxotere); Docetaxel 50562 formulations; Paclitaxel Protein-Bound (Abraxane) and 50562 formulations		1/1/2025	Covered with step therapy where specified; trial of preferred agent required before non-preferred

Biosimilar & Related Preferred Agents

Note

Trastuzumab — preferred products (no step therapy)

Preferred trastuzumab products are designated as no step therapy required effective 1/1/2025; these include Trazimera, Kanjinti, Ogivri, Ontruzant, and Herzuma.

Note

Bevacizumab (oncology) — preferred products (no step therapy)

For oncology indications, bevacizumab biosimilars Mvasi and Zirabev are listed as preferred Part B drugs with no step therapy required effective 1/1/2025.

Note

Rituximab — preferred products (no step therapy)

Preferred rituximab products Ruxience and Truxima are designated no step therapy required effective 1/1/2025.

Note

Colony stimulating agents (long acting) — preferred products (no step therapy)

Long-acting colony stimulating agent products Neulasta and Udenyca are listed as preferred Part B drugs with no step therapy required effective 1/1/2025.

Note

Colony stimulating agents (short acting) — preferred product (no step therapy)

The short-acting colony stimulating agent Zarxio is listed as a preferred Part B drug with no step therapy required effective 1/1/2025.

OpenPayer

Medicare Part B Step Therapy for medically administered drugs

Coverage Criteria & Eligibility

Coding, Lookback & Definitions

Provider Responsibilities & Authorization

Policy Scope & Background

Initial Therapy Preferred Agent Preference

Step Therapy Lists & Effective Dates

Biosimilar & Related Preferred Agents