Medical Preferred Drug List (PDL) — outpatient step therapy and preferred/non-preferred drug designations
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Defines CareFirst CHPMD's Medical Preferred Drug List for outpatient medications, specifying preferred and non-preferred biologic and specialty drugs and that prior authorization and step therapy apply for non-preferred agents. Affects providers prescribing outpatient specialty and medical drugs for CareFirst CHPMD members in Maryland.
No material clinical or coverage changes in this revision.
Coverage Criteria
The policy’s coverage criteria specify that step therapy applies to the outpatient setting only. These step therapy requirements do not apply to care provided in non‑outpatient settings.
Provider Actions & Requirements
Prior authorization required for non-preferred outpatient drugs
Prior authorization is required for all non-preferred medications listed on the Medical PDL in the outpatient setting.
Step therapy (try preferred agents first)
Step therapy applies in the outpatient setting: members may be required to try preferred medications first before the plan will cover non-preferred medications.
Submit prior authorization documentation for non-preferred drugs
Prior authorization documentation must be submitted to support coverage requests for non-preferred medications on the Medical PDL.
Denial risk without PA and step therapy
Requests for non-preferred medications may be denied if prior authorization is not obtained and required step therapy (trying preferred medications first) has not been completed.
Background
This Medical Preferred Drug List (PDL) identifies preferred and non‑preferred medications across multiple specialty and medical drug categories and clarifies how utilization management is applied: prior authorization is required for all non‑preferred medications, and members may be required to try preferred agents first (step therapy) before coverage of non‑preferred agents. These step therapy and prior authorization rules apply in the outpatient setting only.
Definitions
Step Therapy Rules
| Drug class | Preferred medication(s) | Non-preferred medication(s) | Coverage requirement |
|---|---|---|---|
| Bevacizumab (oncology) | Mvasi; Zirabev | Avastin; Alymsys; Jobevne; Vegzelma | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
| Filgrastim | Zarxio | Granix; Leukine; Neupogen; Releuko; Nivestym; Nypozi | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
| Infliximab | Avsola; Inflectra; Renflexis | Remicade; Infliximab | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
| Pulmonary arterial hypertension agents | Treprostinil | Remodulin; Tyvaso | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
| Rituximab | Riabni; Ruxience; Truxima | Rituxan; Rituxan Hycela | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
| Botulinum toxins | Dysport; Xeomin | Botox; Myobloc; Daxxify | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
| Trastuzumab | Kanjinti; Ontruzant | Herceptin; Herceptin Hylecta; Hercessi; Herzuma; Trazimera; Ogivri | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
| Osteoarthritis viscosupplements | Durolane; Euflexxa; Gelsyn-3; Synvisc; Synvisc-one; Triluron; Trivisc; Visco-3 | Gel-One; Genvisc 850; Hyalgan; Hymovis One; Monovisc; Orthovisc; Supartz FX; SynoJoynt | Prior authorization required; members may be required to try preferred medications first (step therapy). Applies to outpatient setting only. |
Site of Care
Outpatient site-of-care: PA and step therapy apply
These prior authorization and step therapy rules apply to medications administered in the outpatient setting.
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