Humana Medicare Part B step therapy Policy Update

Coverage Criteria & Step Therapy Rules

General step therapy requirement

Coverage is subject to step therapy sequencing and exceptions as described below

General step therapy rules: Preferred drugs are the initial step for MA patients; nonpreferred drugs may require prior trial and failure of preferred agents or an approved exception.

Providers must consult Humana coverage policies for specific criteria and prior authorization requirements.

Active treatment exemption

Exemption for ongoing therapy

Active treatment exemption: The step therapy requirement does not apply to patients who are already actively receiving treatment with a nonpreferred drug and have a paid prescription drug claim within the past year.paid claim within past year

Applies to continuity of care; supports members remaining on current nonpreferred therapy.

Step therapy mappings (by class)

Coverage and step therapy are organized by therapeutic class; for each class the plan assigns a step tier mapping (1 = Preferred/Nonpreferred designation, 2 = product, 3 = billing code).

Per-class step mapping: Each therapeutic class lists entries where step 1 indicates preferred or nonpreferred status, step 2 names the specific product, and step 3 provides the associated HCPCS/J/Q code.

Examples include Ophthalmic VEGF inhibitors, Osteoporosis agents, PNH therapies, PD-1/PD-L1 agents for NSCLC, rituximab formulations, trastuzumab formulations, viscosupplements, and others.

The step therapy requirement does not apply to members who are already actively receiving treatment with a nonpreferred drug and who have a paid prescription drug claim within the past year. This active treatment exemption supports continuity of care for patients currently on therapy and exempts them from having to trial a preferred agent before continuing their current nonpreferred medication.

Certain products or drug classes are identified as being covered under the pharmacy (Part D) benefit or as MAPD-only where applicable. Examples in this policy include PCSK9 inhibitors and CGRP therapies, which are noted as Part D benefit / MAPD-only in class-level entries. Providers should confirm benefit assignment (Part B vs Part D or MAPD-only) when submitting coverage or prior authorization requests.

HCPCS / J / Q Codes Mappings

Selected HCPCS/J/Q codes from listHCPCS

J0256	Zemaira / Aralast / Prolastin-C billing code as listed
J0257	Glassia billing code
J1303	Ultomiris billing code
Q5139	Bkemv IV billing code
Q5152	Bkemv IV billing code (alternate)
Q5151	Epannalu/ Epysqli IV billing code
J1300	Soliris billing code
J1299	Soliris billing code (alternate)

Additional HCPCS/J/Q/C codesHCPCS

Q5107	Mvasi (bevacizumab biosimilar) billing code
Q5118	Zirabev billing code
Q5126	Alymsys billing code
J9035	Avastin (bevacizumab) billing code
J0897	Xgeva billing code
J3489	Zoledronic acid billing code
C9257	Avastin ophthalmic billing code (listed as C9257,J9035)
J2778	Lucentis billing code

Colony stimulating/ESA/other codesHCPCS

J2506	Neulasta / Neulasta Onpro billing code
Q5108	Fulphila billing code
J1449	Rolvedon billing code
J0885	Procrit/Epogen billing code
Q5101	Zarxio billing code
J2323	Tysabri billing code

NMOSD - mapped codesHCPCS

J1300
J1299
J1823

Ophthalmic VEGF inhibitors - mapped codesHCPCS

C9257
J9035
Q5124
J0178
J0177
J2778
J2777
J0179
C9093
J3490

Intra-articular steroids and viscosupplement HCPCS/J codesHCPCS

J0702
J1094
J1100
J1020
J1030
J1040
J2920
J2930
J3301
J3302

1–10 of 25

1/3

Various biologics, oncology, osteoporosis, PNH and other product codesHCPCS

J0897
J3489
Q5162
Q5161
Q5158
J3111
J1303
Q5139
Q5152
Q5151

1–10 of 39

1/4

Step tier assignment — mapping (1-3)

Step tier mapping (concise)1 = Preferred or Nonpreferred (plan-level designation); 2 = Product name; 3 = HCPCS/J/Q code

Tier 1 meaningIndicates whether the class entry is designated 'Preferred' (first-line) or 'Nonpreferred' (requires trial of preferred or exception)

Tier 2 meaningSpecifies the exact product name to be used at that step (e.g., Avastin, Eylea, Lucentis)

Tier 3 meaningProvides one or more billing codes associated with the product (HCPCS/J/Q/C codes such as C9257, J9035, J0178)

Provider action implicationProviders must follow the plan's step ordering when requesting Part B-covered drugs for MA enrollees and bill with the associated HCPCS/J/Q codes

Provider Responsibilities, Prior Authorization, and Denial Risk

Prior Authorization

Step therapy may require prior authorization

Step therapy may require prior authorization. Some step therapy strategies require a trial of Humana-preferred products (which may cross benefits between Part B and Part D) before a nonpreferred product will be authorized. Preferred status does not automatically exempt a product from step therapy — always check the specific coverage criteria.

Refer to Humana's Medical and Pharmacy Coverage Policies website for detailed coverage criteria and any step-therapy indicators on the provider prior authorization notification lists.

Denial Risk

Denial trigger

Humana may deny a request for a nonpreferred Part B drug when step-therapy requirements have not been met (for example, trial of preferred alternatives, documentation of medical necessity for bypassing step therapy, or prior authorization not obtained). Denials may also be triggered when a member is not eligible for an exception or when required documentation is missing.

Key Definitions

Active treatment exception (definition)

DefinitionThe step therapy requirement does not apply to patients who are already actively receiving treatment with a nonpreferred drug and have a paid prescription drug claim within the past year.

Timeframe for exemptionPaid prescription drug claim within the past year is required to qualify for the active treatment exception.

ScopeApplies to continuity of care for Medicare Advantage members receiving Part B-covered drugs under Humana's step therapy policy.

Member rightsMembers subject to step therapy retain the right to request expedited exception reviews and to appeal denials related to step therapy.

Provider guidanceProviders should consult Humana's coverage criteria and prior authorization notification lists for any additional requirements when submitting requests involving active treatment exceptions.

Initial Therapy Preferences

Initial therapy preference — Preferred agents listed as first-step agents within therapeutic categories

Preferred agents listed as first-step agents within therapeutic categories

Initial preferred agent use: When a therapeutic category lists a Preferred agent (status = Preferred), that agent is the initial step expected under step therapy for MA members; use of Nonpreferred agents generally requires prior trial/failure of the Preferred agent or an exception.

Specific exceptions and prior authorization criteria are maintained in Humana coverage policies.

Preferred initial products

Preferred products for initial therapy in certain classes

Preferred initial products: Entries labeled '1 = Preferred' indicate preferred products for initial use (e.g., several ophthalmic VEGF inhibitors, viscosupplements, certain biologics).

See class-specific list for exact products and codes.

Continuation / Active Treatment Exemptions

Continuation therapy (active treatment exemption)

Continuation/ongoing therapy provision

Continuing patients: Members already actively treated with a nonpreferred drug with a paid claim within the past year are not subject to step therapy and may continue therapy.paid claim within past year

Supports continuity of care.

Step Therapy Tables by Therapeutic Category

Therapeutic category	Step 1 (Preferred/Nonpreferred)	Step 2 (Product)	Step 3 (HCPCS / J / Q code)
Alpha-1s	Preferred	Zemaira	J0256
Alpha-1s	Nonpreferred	Aralast	J0256
Alpha-1s	Nonpreferred	Glassia	J0257
Atypical Hemolytic Uremic Syndrome (aHUS)	Preferred	Ultomiris	J1303
Atypical Hemolytic Uremic Syndrome (aHUS)	Nonpreferred	Bkemv IV	Q5139; Q5152
Bevacizumab (oncology)	Preferred	Mvasi	Q5107
Bevacizumab (oncology)	Preferred	Zirabev	Q5118
Bone resorption inhibitors	Preferred	Xgeva	J0897
Colony Stimulating Factors - leukocyte growth factors (long-acting)	Preferred	Fulphila	Q5108
Erythropoiesis-stimulating agents	Preferred	Procrit	J0885
Neuromyelitis Optica Spectrum Disorder (NMOSD)	Nonpreferred	Soliris / Uplizna (listed per entry)	J1300, J1299, J1823
Ophthalmic disorders - VEGF inhibitors	Preferred	Avastin (for ophthalmic use listed)	C9257, J9035
Ophthalmic disorders - VEGF inhibitors	Preferred	Eylea	J0178
Osteoarthritis of the knee (intra-articular steroids)	Preferred	Betamethasone	J0702
Osteoporosis	Preferred	Prolia	J3111
PNH (Paroxysmal nocturnal hemoglobinuria)	Preferred	Ultomiris	J1303

Class	Step mapping (1 = status)	Step mapping (2 = product)	Step mapping (3 = code)
Ophthalmic disorders - VEGF inhibitors	1 = Preferred	2 = Avastin / Byooviz / Eylea / Eylea HD / Lucentis / Pavblu / Vabysmo	3 = C9257; J9035; Q5124; J0178; J0177; J2778; Q5147; J2777
Bevacizumab (oncology)	1 = Preferred / Nonpreferred assigned per product	2 = Mvasi; Zirabev; Alymsys; Avastin; Jobevne; Vegzelma	3 = Q5107; Q5118; Q5126; J9035; Q5160; Q5129
Viscosupplements (intra-articular)	1 = Preferred / Nonpreferred assigned per product	2 = Durolane; Monovisc; Orthovisc; Supartz FX; Synvisc One; Euflexxa; Gel-One; Gelsyn-3; GenVisc 850; Hyalgan; Hymovis; Synvisc; Triluron; TriVisc; Visco-3	3 = J7318; J7327; J7324; J7321; J7325; J7323; J7326; J7328; J7320; J7321; J7322; J7325; J7332; J7329; J7333
Neuromyelitis Optica Spectrum Disorder (NMOSD)	1 = Nonpreferred	2 = Soliris; Uplizna	3 = J1300; J1299; J1823
Osteoporosis	1 = Preferred / Nonpreferred per product	2 = Prolia; zoledronic acid; Evenity; Bildyos; Bosaya; Conexxence; Ospomyv; Stoboclo	3 = J0897; J3489; J3111; Q5162; Q5161; Q5158; Q5159; Q5157
PD-1/PD-L1 agents (NSCLC)	1 = Preferred / Nonpreferred per product	2 = Libtayo; Imfinzi; Imjudo; Keytruda; Keytruda Qlex; Opdivo; Tecentriq (SQ/IV); Yervoy	3 = J9119; J9173; J9347; J9271; J9277; J9299; J9024; J9022; J9228

Site of Care and Dispensing

Note

Obtain preferred drug from pharmacy if not stocked in office

If prescribers do not stock Humana's preferred drug in their office, the preferred drug may be obtained from a pharmacy and shipped to the office; Humana provides a list of specialty and mail-order pharmacies and a pharmacy finder tool.

Call 800-457-4708 (TTY: 711) or use the pharmacy finder tool to locate participating pharmacies.

Biosimilar Preferences

Billing Rule

Preferred bevacizumab biosimilars (Mvasi, Zirabev)

Humana lists bevacizumab biosimilars (Mvasi, Zirabev) as preferred for oncology bevacizumab uses while some branded and other bevacizumab products are listed as nonpreferred.

Mvasi (Q5107) and Zirabev (Q5118) are shown as Preferred for oncology bevacizumab.

Step Therapy

Preferred biosimilar option for oncology bevacizumab

For oncology bevacizumab indications, Mvasi and Zirabev are designated Preferred and are the plan's preferred biosimilar options for initial use.

Billing Rule

Policy Background

This policy provides administrative direction on step therapy sequencing (preferred vs nonpreferred) across multiple therapeutic categories for Medicare Advantage members receiving Medicare Part B–covered drugs. For each class the plan assigns a step mapping (step 1 indicates preferred/nonpreferred status; subsequent steps name the product and list the associated billing code) and documents cross-benefit strategies when trials may include Part D agents. Providers should consult Humana’s coverage criteria and prior authorization notification lists for class-specific requirements and any cross-benefit trial expectations.

OpenPayer

Medicare Part B step therapy requirement for Medicare Advantage plans

Coverage Criteria & Step Therapy Rules

HCPCS / J / Q Codes Mappings

Provider Responsibilities, Prior Authorization, and Denial Risk

Key Definitions

Initial Therapy Preferences

Continuation / Active Treatment Exemptions

Step Therapy Tables by Therapeutic Category

Site of Care and Dispensing

Biosimilar Preferences

Policy Background