CurrentFlorida BluePolicy N/A

Medicare Advantage Part B Step Therapy — Preferred and Non‑Preferred Drug Categories

Defines updates to the Part B Step Therapy program for Florida Blue Medicare Advantage (BlueMedicare) plans, listing preferred and non-preferred Part B drugs by category and indicating that step therapy and medical necessity requirements apply.

Policy Summary

PayerFlorida Blue

PolicyMedicare Advantage Part B Step Therapy — Preferred and Non‑Preferred Drug Categories

Policy CodePolicy N/A

Change TypeAdded and removed Part B Step Therapy categories

Effective DateJul 15, 2025

Next Review DateN/A

Key ActionPrescribe preferred alternatives first or submit prior authorization and documentation showing medical necessity when requesting coverage for non‑preferred Part B drugs.

SourceLink

POLICY UPDATE CHANGES

Three updated categories were added to the Part B Step Therapy program effective July 15, 2025, and one category was removed.

2025-07-15policy effective date

4drug categories mentioned

Step Therapycoverage mechanism

Preferred vs Non-Preferredstatus distinctions

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General Step Therapy and Medical Necessity Criteria

Covered when ALL of the following are met

Step Therapy Requirement: Provider must follow Part B Step Therapy: prescribe preferred alternatives first or meet step therapy exceptions; prior authorization may be required.

Applies to non-preferred medications listed in categories.

Medical Necessity: Medical necessity definition must be met for coverage of non-preferred medications.

Document indication and prior treatments; see prior authorization rules.

One category was removed from the Part B Step Therapy program effective July 15, 2025. This operational change applies to Florida Blue Medicare Advantage (BlueMedicare) Part B Step Therapy and updates the program’s category list for plan administration.

Coding / HCPCS Listings

Erythropoiesis Stimulating Agents - Preferred HCPCSHCPCSCovered

Q5106

Retacrit* (Preferred)

Erythropoiesis Stimulating Agents - Non-Preferred HCPCSHCPCSNot Covered

J0885	Procrit/Epogen (Non-Preferred)
J0881	Aranesp* (Non-Preferred)
J0888	Mircera* (Non-Preferred)

Cancer and Supportive Therapy - Preferred HCPCSHCPCSCovered

J1626	granisetron/ondansetron/palonosetron (Preferred)
J2405	granisetron/ondansetron/palonosetron (Preferred)
J2469	granisetron/ondansetron/palonosetron (Preferred)
J1453	fosaprepitant (Preferred)

Cancer and Supportive Therapy - Non-Preferred HCPCSHCPCSNot Covered

J1627	granisetron/ondansetron/palonosetron (Non-Preferred)
J2468	granisetron/ondansetron/palonosetron (Non-Preferred)
J1434	fosaprepitant (Non-Preferred)
J0185	fosaprepitant (Non-Preferred)

Complement Inhibitors - Preferred HCPCSHCPCSCovered

J1303	Ultomiris (Preferred)
J9332	Vyvgart (Preferred)
J9334	Vyvgart Hytrulo (Preferred)
J9333	Rystiggo (Preferred)
C9399	C9399 (Preferred for certain products)
J3490	J3490 (Preferred for certain products)

Complement Inhibitors - Non-Preferred HCPCSHCPCSNot Covered

J1300	Soliris (Non-Preferred)
J1299	Soliris (Non-Preferred)
J1307	Soliris (Non-Preferred)
Q5152	Soliris (Non-Preferred)
Q5151	Soliris (Non-Preferred)
J3590	J3590 (Non-Preferred)

Provider Actions and Requirements

Prior Authorization

Step Therapy and Prior Authorization

Step Therapy is required for certain non-preferred Part B medications. Prior authorization may apply when prescribing preferred alternatives and is required for certain non-preferred drugs. Encourage use of preferred alternatives (listed in the formulary) before initiating a non-preferred product.

Step Therapy applies to select non-preferred Part B drugs; providers should attempt preferred alternatives first.
Prior authorization may be required for both preferred alternatives and non-preferred medications — submit PA when indicated.

Denial Risk

Denial Risk for Non-Preferred Drugs

Use of non-preferred Part B medications without meeting Step Therapy requirements and documenting medical necessity may result in claim denials or treatment not being covered.

Denial risk if Step Therapy not attempted or prior authorization not obtained.
Non-preferred products listed in the formulary may be denied if medical necessity is not demonstrated.

Documentation Required

Documentation and Coding Support

Document the clinical indication, prior use and response (or intolerance) to preferred alternatives, and the specific medical necessity for selecting a non-preferred agent. Include applicable HCPCS/diagnosis codes and attach supporting clinical records when submitting prior authorization requests.

Document: diagnosis, prior therapies tried, dates of trials, clinical response or adverse effects.
Include relevant HCPCS codes (e.g., J-codes and Q-codes listed in the formulary) and applicable ICD-10 diagnosis codes on the PA and claim.
Attach chart notes, labs, and prior medication history to support medical necessity.

Billing Rule

Billing and HCPCS Coding

When billing, use the correct HCPCS codes for the preferred or non-preferred product administered. If a product is covered under a specific HCPCS or Q-code mapping in the formulary, bill that code and include the PA number when required to expedite adjudication.

Bill using the HCPCS/Q-codes associated with the product administered (refer to formulary code mappings).
Include the prior authorization number on the claim when a PA was obtained to prevent processing delays.

Initial Therapy Preference

Initial therapy preference

Preferred product use is encouraged before non-preferred products; prior authorization may apply.

Try Preferred Product First: Prescribe a listed preferred product for the drug category prior to a non-preferred product unless contraindicated or there is documented medical necessity for an exception.

Prior authorization may be required for exceptions; document prior trials or contraindications.

Step Therapy Rules

Step	Requirement	Provider Action
1	Step Therapy is required for non-preferred Medicare Advantage Part B drugs.	Prescribe a listed preferred alternative product from the applicable category prior to coverage of a non-preferred product; document trials or contraindications to support an exception.
2	Prior authorization may be required for preferred alternatives and is required for certain non-preferred medications under Step Therapy.	Submit prior authorization when required and include documentation of indication and prior use of preferred alternatives; use the HCPCS codes provided in the policy to support claims and authorization.
3	Medical necessity definition must be met for coverage of non-preferred medications; failure to meet Step Therapy and medical necessity may result in denial.	Ensure clinical documentation demonstrates medical necessity and that preferred therapies were tried and failed or are contraindicated; retain records to support appeal if a denial occurs.

Definitions

Definition of Step Therapy

DefinitionStep Therapy is a utilization management program that requires trials of preferred alternatives and meeting the payer's medical necessity criteria before covering certain non-preferred medications.

Provider expectationPrescribe a listed preferred product for the drug category prior to a non-preferred product unless contraindicated or documented medical necessity for exception.

Prior authorizationPrior authorization may apply when prescribing preferred alternatives and is required for certain non-preferred medications under Step Therapy.

Documentation requirementDocument indication and prior use (or intolerance/contraindication) of preferred alternatives to support step therapy exception or medical necessity.

Coverage consequenceUse of non-preferred Part B medications without meeting Step Therapy and the medical necessity definition may trigger denial of coverage.