Medicare Part B drugs subject to step therapy
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Lists Medicare Part B drugs subject to step therapy at Independence Blue Cross, identifying preferred and non-preferred products by drug category and describing the plan's step therapy approach for Medicare members.
No material clinical or coverage changes in this revision.
Coverage criteria — step therapy conditions
Step therapy coverage condition
Covered when ALL of the following are met
Preferred products and non-preferred products are listed by drug category in this policy (e.g., cancer agents, colony-stimulating factors, IV iron, IVIG, ophthalmologic VEGF agents, denosumab, etc.). See the category lists for specific product mappings.
The lists of Medicare Part B drugs subject to step therapy in this document are not exhaustive. For a complete listing or for clarification about whether a specific drug is subject to step therapy, providers and members should contact the IBX Help Team at 1-800-ASK-BLUE (available 8 a.m. to 8 p.m., Monday–Friday) or visit ibx.com/medicare. Coverage rules and the preferred/non‑preferred drug lists are subject to change; when in doubt, confirm current requirements with IBX prior to initiating or billing for non-preferred products.
What providers need to do
Step therapy requirement — try preferred product first
Independence Blue Cross may require members to try a plan-designated preferred product before IBX will cover a non-preferred Medicare Part B drug (step therapy).
Step therapy process — preferred-product trial required
The plan designates certain drugs as preferred products that members must try before IBX will cover non-preferred products; requirements and the specific preferred-product lists are available in the medical policies and the list is subject to change.
- Preferred-product requirements are available in IBX medical policies.
- The list of preferred and non-preferred products is subject to change.
Help/contact for coverage details
For a complete listing of preferred and non-preferred Medicare Part B drugs or for clarification, providers or members should call the IBX Help Team or visit ibx.com/medicare.
- Call 1-800-ASK-BLUE, 8 a.m. to 8 p.m., Monday–Friday.
- Visit ibx.com/medicare for listings and details.
Denial risk — non-preferred drugs without prior preferred trial
Coverage for a non-preferred product may be denied unless the member has first tried a plan-designated preferred product in accordance with the step therapy process.
Key definitions
Background and rationale
Step therapy is used when multiple treatment options demonstrate similar clinical outcomes. Under this utilization management approach, the plan designates preferred products within a drug category that members are required to try before the plan will cover a non-preferred product. The intent is to standardize initial therapy around preferred agents; if a member fails to respond to or is intolerant of a preferred agent (or has another clinically acceptable reason), the plan may then consider coverage of an alternative non-preferred product.
Initial therapy — preferred product trial
Initial therapy step — Preferred-product trial
Preferred-product trial
Preferred products by category are listed in this policy (see categories such as IV iron Level 1, oncology agents, CSFs, IVIG, ophthalmologic VEGF agents, etc.).
Step therapy drug lists and required trials
| Drug category | Preferred product(s) | Non-preferred product(s) | Coverage requirement |
|---|---|---|---|
| Cancer | Eligard®, Camcevi®, Lupron depot®; Alymsys®, Avastin®, Avzivi®, Herceptin®, Hercessi®, Herceptin Hylecta™, Herzuma®; Riabni™, Ruxience®, Truxima™ | Camcevi®, Trazimera™ and other listed non-preferred oncology products per policy | Member must try designated preferred product(s) for the cancer category before IBX will cover a non-preferred product. |
| Colony-stimulating factors (long-acting) | Fulphila™, Neulasta® | Fylnetra™, Nyvepria®, Rolvedon®, Stimufend®, Udenyca®, Ziextenzo™ | Member must try designated preferred long-acting CSF prior to coverage of non-preferred long-acting CSF. |
| Colony-stimulating factors (short-acting) | Nivestym®, Zarxio® | Neupogen®, Granix®, Releuko® | Member must try designated preferred short-acting CSF prior to coverage of non-preferred short-acting CSF. |
| Denosumab products | Jubbonti®, Stoboclo®, Osenvelt®, Wyost® | Aukelso™, Bildyos®, Bilprevda®, Bomyntra®, Bosaya™, Connexence®, Enoby®, Ospomyv®, Prolia®, Xbryk®, Xgeva®, Xtrenbo® | Member must try designated preferred denosumab product(s) before denosumab-branded non-preferred products will be covered. |
| Eculizumab products | Epysqli® | Soliris®, Bkemv® | Member must try Epysqli® (preferred) before IBX will cover non-preferred eculizumab products. |
| Hyaluronate acid products | Monovisc®, Orthovisc®, Synvisc®, Synvisc-One® | Durolane®, Euflexxa™, Gel-One®, Gelsyn3™, GenVisc-850®, Hyalgan®, Hymovis®, Supartz®, Synojoynt™, Triluron™, TriVisc™, VISCO-3® | Member must try a plan-designated preferred hyaluronate product before coverage of non-preferred products in this class. |
| Infliximab products | Avsola™, Inflectra®, Infliximab (unbranded), Ixifi®, Remicade®, Renflexis® | (No separate non-preferred infliximab products listed; policy identifies preferred infliximab products) | Member must try a preferred infliximab product before IBX will cover a non-preferred infliximab product. |
| IV Iron | Preferred products (Level 1): All generic IV Iron (Feraheme®, Ferrlecit®, INFeD®, Venofer®) | Non-preferred products (Level 2): Injectafer®, Monoferric® | Member must try Level 1 preferred IV iron products before coverage of Level 2 non-preferred IV iron products. |
| Intravenous Immune Globulin (IVIG) | Bivigam®, Cutaquig®, Cuvitru®, Flebogamma®, Flebogamma DIF®, Gamastan S/D®, Gammagard Liquid®, Gammagard S/D®, Gammaked®, Gammaplex®, Gamunex-C®, Hizentra®, HyQvia®, Octagam®, Privigen®, Xembify®, Yimmugo® | Alyglo®, Asceniv®, Panzyga® | Member must try designated preferred IVIG product(s) before IBX will cover non-preferred IVIG products. |
| Myasthenia Gravis agents | Vyvgart®, Rystiggo® | Imaavy®, Ultomiris®, Epysqli®, Soliris®, Bkemv™ | Member must try Vyvgart® or Rystiggo® (preferred) before coverage of non-preferred MG agents. |
| Ophthalmologic VEGF agents | Preferred products (Level 1): Alymsys®, Avastin®, Avzivi®, Mvasi®, Vegzelma®, Zirabev® | Non-preferred products (Level 2 and 3): Byooviz™, Cimerli®, Lucentis® | Member must try a Level 1 preferred ophthalmologic VEGF product before IBX will cover Level 2/3 non-preferred ophthalmologic VEGF products. |
| Ustekinumab products | Yesintek™ | Imuldosa™, Otulfi®, Pyzchiva®, Selarsdi™, Starjezma®, Stelara®, Steqeyma®, Wezlana™ | Member must try Yesintek™ (preferred) before coverage of non-preferred ustekinumab products. |
| Tocilizumab products | Tyenne® | Actemra®, Avtozma®, Tofidence™ | Member must try Tyenne® (preferred) before IBX will cover non-preferred tocilizumab products. |
Biosimilar guidance
Infliximab originator (Remicade®) listed as preferred
Remicade® (the infliximab originator) is listed among IBX’s preferred infliximab products.
- Preferred infliximab products include Avsola™, Inflectra®, Infliximab (unbranded), Ixifi®, Remicade®, Renflexis®
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