CurrentFlorida BluePolicy N/A

Part B Step Therapy for BlueMedicare (Bone remodeling drugs)

Defines a Part B step therapy program change for BlueMedicare Medicare Advantage effective June 15, 2024, adding a category affecting prescribing of certain higher-cost non-preferred bone remodeling agents and encouraging use of preferred alternatives.

Policy Summary

PayerFlorida Blue

PolicyPart B Step Therapy for BlueMedicare (Bone remodeling drugs)

Policy CodePolicy N/A

Change TypeAdded Part B step therapy category

Effective DateJun 15, 2024

Next Review DateN/A

Key ActionPrescribe preferred alternatives before coverage of listed non-preferred bone remodeling drugs per the Part B step therapy program.

SourceLink

POLICY UPDATE CHANGES

BlueMedicare Medicare Advantage plans added one category to the Part B step therapy program for members.

1new category added

Bone Remodelingtherapeutic category

Zoledronic acid, Prolia, Evenityexample products

Coverage and Medical Necessity Criteria

Coverage criteria for non-preferred Part B bone remodeling agents

Covered when ALL of the following are met

Step therapy requirement: Member has tried a preferred alternative agent(s) as required by the Part B step therapy program

Preferred alternative example: J3489 (zoledronic acid) listed as preferred in the policy; specific trial duration or number of trials not specified in document.

Medical necessity: The definition of medical necessity is met for the requested non-preferred higher-cost medication

Policy states the definition of medical necessity must be met but does not provide specific diagnostic criteria in the document.

None explicitly listed in the source document.

Use of non-preferred higher-cost medications may be denied if the member has not first met the Part B step therapy requirements and the provider has not demonstrated that the definition of medical necessity is met for the requested non-preferred agent. Providers are encouraged to prescribe preferred alternatives prior to requesting coverage of non-preferred products.

Policy Summary

PayerFlorida Blue

PolicyPart B Step Therapy for BlueMedicare (Bone remodeling drugs)

Policy CodePolicy N/A

Change TypeAdded Part B step therapy category

Effective DateJun 15, 2024

Next Review DateN/A

Key ActionPrescribe preferred alternatives before coverage of listed non-preferred bone remodeling drugs per the Part B step therapy program.

SourceLink

On This Page

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What Providers Must Do

Step Therapy

Part B Step Therapy Required

Part B Step Therapy requirement: For select bone remodeling agents, step therapy is required and the payer will cover non-preferred, higher-cost medications only after the definition of medical necessity is met and required preferred alternatives have been tried.

Step therapy applies to certain bone remodeling drugs furnished under Medicare Part B.
Providers must document that the member has tried and not adequately responded to the preferred alternative(s) before coverage of the listed non-preferred product will be approved.
Medical necessity criteria must also be met for step-therapy-required drugs.

Note

Prescribe Preferred Alternatives First

Providers should prescribe the listed preferred alternatives prior to requesting coverage for the non-preferred bone remodeling drugs subject to the Part B step therapy program.

Preferred alternative for zoledronic acid: HCPCS J3489.

Denial Risk

Denial Risk for Non-Preferred, Higher-Cost Drugs

Use of certain higher-cost non-preferred medications (for example, Prolia, Evenity, J0897, J3111) without documented trial of the preferred alternative(s) and without meeting the medical necessity requirements may result in denial of payment.

Non-preferred bone remodeling products include: Prolia, Evenity, HCPCS J0897, HCPCS J3111.
Denial risk exists if step therapy and medical necessity requirements are not met.

Note

Encouragement to Prescribe Preferred Alternatives and Document Medical Necessity

We encourage prescribers to use the preferred, lower-cost alternatives when clinically appropriate and to ensure documentation supports trials and medical necessity when requesting coverage for step-therapy-required, non-preferred agents.

Document prior trials of preferred products and clinical rationale for any exception.
Submit required supporting records when requesting coverage for non-preferred agents under step therapy.

Policy Background

Step therapy is a program that requires trial of preferred alternatives before coverage of certain higher-cost, non-preferred medications. This policy change adds a Part B step therapy category affecting bone remodeling agents effective June 15, 2024; for these agents the insurer requires that members try preferred alternatives (for example, products identified as preferred in the Bone Remodeling listing) and that the definition of medical necessity be met before a non-preferred product will be covered.

The document lists specific examples to guide prescribing: J3489 is identified as a preferred zoledronic acid product, while J0897 (Prolia) and J3111 (Evenity) are listed as non-preferred. Providers should consider these preferred alternatives when initiating therapy to avoid delays or denials associated with the Part B step therapy program.

Key Definitions

Step therapy — definition and implications

DefinitionStep therapy is a program that requires trial of preferred alternative agent(s) and meeting the definition of medical necessity before covering certain non-preferred higher‑cost medications.

Required actions for providersPrescribe preferred alternative(s) prior to coverage of listed non‑preferred bone remodeling drugs under the Part B step therapy program.

Coverage implicationCoverage for a non‑preferred higher‑cost medication is contingent on documented trial of preferred alternatives and meeting medical necessity criteria.

Denial riskUse of non‑preferred higher‑cost medications without meeting step therapy and medical necessity requirements may result in denial under the Part B step therapy program.

OpenPayer

Part B Step Therapy for BlueMedicare (Bone remodeling drugs)

Coverage and Medical Necessity Criteria

HCPCS / Billing Codes

What Providers Must Do

Policy Background

Key Definitions

Initial Therapy Requirements

Step Therapy Program Details