CurrentEmblemHealthPolicy N/A

Part B Step Therapy Drug List

Lists Part B drugs subject to step therapy for new starts and indicates preferred vs non-preferred products and HCPCS codes; applies to EmblemHealth Part B drug coverage beginning January 1, 2021 and affects providers prescribing/administering these drugs to members.

Policy Summary

PayerEmblemHealth

PolicyPart B Step Therapy Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionRequire step therapy for listed Non-Preferred Part B drugs for members who are new starts; members with a paid claim in the past 365 days are exempt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2021-01-01effective date for step therapy requirement

new starts onlystep therapy population

365 dayslookback period to exempt current users

multiple classesdrug categories listed

PA requiredauthorization note

Policy Summary

PayerEmblemHealth

PolicyPart B Step Therapy Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionRequire step therapy for listed Non-Preferred Part B drugs for members who are new starts; members with a paid claim in the past 365 days are exempt.

SourceLink

On This Page

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Part B Step Therapy Coverage Criteria

Covered when ALL of the following are met:

Step therapy will be applied to listed Non-Preferred Part B drugs for members who are new starts; existing members with a paid claim within the past 365 days are exempt.

Applies for dates of service on or after January 1, 2021.

'New starts' are members initiating therapy with a Non-Preferred product after the policy effective date; members with a paid claim for the same product within the prior 365 days are exempt.

The specific Part B products and HCPCS codes subject to step therapy are those enumerated on the Part B Step Therapy Drug List (includes multiple hyaluronan injections, colony stimulating factors — short- and long-acting, erythropoietic agents, infliximab products, and numerous antineoplastic agents).

See coding table for full HCPCS list and preferred status.

Preferred-status products listed in the document also require prior authorization per the policy note.

Preferred products are subject to prior authorization in addition to the step-therapy framework.

Some antineoplastic listings are limited to oncology indications only.

Policy denotes oncology indications only for certain antineoplastic entries.

Listed Part B HCPCS Codes and Products

Listed Part B HCPCS codes and productsHCPCS

J7326	Gel-One (Hyaluronan Injection)
J7325	Synvisc / Synvisc-One (Hyaluronan Injection)
J7321	Hyalgans / Supartz FX / Visco 3 (Hyaluronan Injections)
J7322	Hymovis (Hyaluronan Injection)
J7327	Monovisc (Hyaluronan Injection)
J7324	Orthovisc (Hyaluronan Injection)
J7329	Trivisc (Hyaluronan Injection)
J7318	Durolane (Hyaluronan Injection)
J7332	Triluron (Hyaluronan Injection)
J7331	Synojoynt (Hyaluronan Injection)

1–10 of 48

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Provider Actions and Authorization Notes

Prior Authorization

Prior Authorization Required for Preferred Products

Preferred products also require prior authorization. Providers must obtain prior authorization before administering preferred Part B antineoplastic products listed on the plan.

Applies to Preferred Part B products (e.g., Zirabev Q5118)
Prior authorization required prior to administration or claim submission

Step Therapy

Step Therapy Exemption for Current Users

Step therapy requirements apply to new starts only. Members who have been actively receiving a non-preferred product within the past 365 days (a paid claim in the last 365 days) are exempt from step therapy.

Step therapy exemption: member has a paid claim within the past 365 days
Effective for dates of service on or after 2021-01-01

Key Definitions

New starts (definition)

DefinitionMembers initiating therapy with a Non-Preferred product after the policy effective date; existing members with a paid claim within the prior 365 days are exempt.

Applies to'New starts' only — members not currently and actively receiving the Non-Preferred therapy (no paid claim in past 365 days).

Effective dateStep therapy applies for dates of service on or after January 1, 2021.

Lookback period365-day paid-claim lookback to determine exemption for existing users.

Non-Preferred (definition)

DefinitionProducts on this list subject to step therapy requirements (designated 'Non-Preferred').

ScopeThe listed Non-Preferred Part B drugs will be subject to step therapy pursuant to CMS HPMS guidance (HPMS memo Aug 7, 2018).

ObjectiveIntended to lower drug prices while maintaining access to covered services and drugs for members.

Implementation noteStep therapy requirements apply only to new starts; members actively treated within 365 days are exempt.