Medical Preferred Drug List — Outpatient Step Therapy and Prior Authorization
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Defines preferred and non-preferred medications and step therapy/prior authorization expectations for outpatient medications under CareFirst CHPMD; affects providers prescribing covered drugs to plan members in Maryland.
No material clinical or coverage changes in this revision.
Coverage Criteria — Medical Preferred Drug List (Outpatient)
General outpatient PDL requirements
Coverage for listed medications is governed by the Medical PDL with the following utilization management approach:
Members already being treated with non-preferred medications are exempt from the step requirement.
The CareFirst Medical Preferred Drug List (PDL) requires a step therapy approach in the outpatient setting: prior authorization is required for all non-preferred medications, and members may need to try preferred medications first before the plan will cover non-preferred agents. The step therapy requirement does not apply to members who are already being treated with non-preferred medications.
Provider Actions & Requirements
Prior authorization required (outpatient non-preferred meds)
Prior authorization is required for all non-preferred medications listed on the Medical PDL when prescribed in the outpatient setting.
Step therapy applies (outpatient only)
Members may be required to try preferred medications first (step therapy) before the plan will cover non-preferred outpatient medications; this step requirement does not apply to members already being treated with non-preferred medications.
Prior authorization documentation required
When requesting prior authorization for non-preferred outpatient medications, providers must include documentation of prior trials of preferred agents when step therapy is applicable.
Denial risk if no prior authorization or step completion
Requests for non-preferred outpatient medications submitted without prior authorization or without meeting step therapy requirements may be denied.
Background
This policy lists preferred and non-preferred products across multiple therapeutic categories to guide outpatient prescribing and utilization management. Categories include oncology biologics (e.g., bevacizumab, trastuzumab), filgrastim biosimilars, infliximab and rituximab biosimilars, pulmonary arterial hypertension agents, botulinum toxins, and osteoarthritis viscosupplements. Prior authorization and step therapy statements in this document apply to the outpatient setting only.
Definitions
Step Therapy Rules
| Requirement | Details |
|---|---|
| Step therapy (outpatient) | |
| Members may need to try preferred medications first before the plan will cover non‑preferred medications; applies to the outpatient setting only. | |
| Prior authorization | |
| Prior authorization is required for all non‑preferred medications listed on the Medical PDL. | |
| Exemption for current users | |
| The step therapy requirement does not apply to members who are already being treated with non‑preferred medications. |
Site of Care — Outpatient Applicability
Outpatient setting only
Step therapy and prior authorization statements in this PDL apply only to medications administered or requested in the outpatient setting.
Biosimilar Preferences and Non-preferred Biologics
Bevacizumab (Avastin) - preferred biosimilars listed
Mvasi and Zirabev are listed as preferred bevacizumab products; Avastin and other bevacizumab products are listed as non-preferred.
Filgrastim (Neupogen) - preferred biosimilar listed
Zarxio is listed as the preferred filgrastim product; Neupogen and other filgrastim products are listed as non-preferred.
Infliximab (Remicade) - preferred biosimilars listed
Avsola and Inflectra are listed as preferred infliximab products; Remicade and other infliximab products are listed as non-preferred.
Rituximab (Rituxan) - preferred biosimilars listed
Riabni and Truxima are listed as preferred rituximab products; Rituxan and other rituximab products are listed as non-preferred.
Trastuzumab (Herceptin) - preferred biosimilars listed
Kanjinti and Ontruzant are listed as preferred trastuzumab products; Herceptin and other trastuzumab products are listed as non-preferred.
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