Step Therapy Criteria for Medicare Part B Drugs
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Defines step therapy (prior-authorization) requirements for specific Medicare Part B drugs under Independent Health Medicare Advantage plans for 2026; applies to new therapy starts and describes required prior treatments or failures before coverage is approved.
No material clinical or coverage changes in this revision.
Coverage Criteria
Zilretta
Covered when ALL of the following are met for new starts:
Provider Actions and Documentation
Require prior bevacizumab trial (Avastin) for new starts
For new therapy starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to bevacizumab (Avastin).
- Applies to specified ophthalmic agents (new starts only).
Document trial and failure of Onpattro before AMVUTTRA
Prior authorization for AMVUTTRA new starts requires documentation that the patient tried and failed to have an adequate response to Onpattro.
- This requirement applies to new starts only.
Require prior plerixafor trial for APHEXDA
Prior authorization for APHEXDA new starts requires documentation that the patient tried and failed to have an adequate response to plerixafor.
- This requirement applies to new starts only.
Document trial and failure of another IVIG before Asceniv
For Asceniv new starts (shared indications), prior authorization requires documentation that the patient tried and failed to have a response to another IVIG product.
- Does not apply when Asceniv is used for an indication not shared with preferred IVIG products.
Require trial of Mvasi or Zirabev before certain bevacizumab agents
Prior authorization for listed oncology bevacizumab agents requires evidence that the patient tried and had an inadequate response to the preferred bevacizumab biosimilars Mvasi or Zirabev.
- Applies to Alymsys, Avastin (oncology), Jobevne, or Vegzelma for oncology indications (new starts only).
- Does not apply to ophthalmic Avastin uses or indications not shared with Mvasi/Zirabev.
Document trial and inadequate response to specified denosumab biosimilars
Prior authorization for Prolia, Xgeva, or non-preferred denosumab biosimilars on new starts requires documentation that the patient tried and failed to have an adequate response to the specified preferred denosumab biosimilars.
- For Prolia/non-preferred Prolia biosimilars: trial and failure of Bildyos or Jubbonti required.
- For Xgeva/non-preferred Xgeva biosimilars: trial and failure of Bilprevda or Wyost required.
- Does not apply when indication is not shared with the preferred biosimilars.
Require documented trial of Ruxience or Riabni before rituximab products
Prior authorization for listed rituximab-affected products on new starts requires documentation that the patient tried and failed to have an adequate response to Ruxience, Riabni, or another rituximab product.
- Failure to document prior trial and inadequate response may trigger denial.
Document trial and failure of Retacrit for epoetin alfa alternatives
Prior authorization for epoetin alfa alternatives on new starts requires documentation that the patient tried and failed to have an adequate response to Retacrit.
- Does not apply to patients using Epogen or Procrit for indications not shared with Retacrit.
Require Zarxio trial and inadequate response for G‑CSF products
Prior authorization for listed granulocyte‑colony stimulating factor products on new starts requires documentation that the patient tried and failed to have an adequate response to Zarxio.
- Does not apply when the patient is using a non-preferred agent for an indication not shared with Zarxio.
Document required prior paliperidone palmitate treatment for Invega Hafyera
Prior authorization for Invega Hafyera new starts requires proof of prior paliperidone palmitate extended‑release treatment as specified (≥4 months of 1‑month formulation or at least one 3‑month injection).
- Documentation must show duration and formulation of prior paliperidone palmitate treatment.
- Lack of such documentation may trigger denial.
Document ≥4 months' 1‑month paliperidone palmitate before Invega Trinza
Prior authorization for Invega Trinza new starts requires documentation of at least 4 months' treatment with 1‑month paliperidone palmitate extended‑release injectable suspension.
- Absence of this documentation may trigger denial.
Require trial and failure of generic leucovorin before Khapzory
Prior authorization for Khapzory new starts requires documentation that the patient tried and failed to have an adequate response to generic leucovorin.
- Does not apply when the patient is using levoleucovorin for indications not shared with leucovorin.
Document Jivi failure for hemophilia factor product approvals
Prior authorization for Adynovate, Eloctate, or Esperoct new starts requires documentation that the patient tried and failed to have an adequate response to Jivi.
- Records indicating prior use and inadequate response to Jivi are required; absence may cause denial.
Require Tyruko trial and failure before Tysabri
Prior authorization for Tysabri new starts requires documentation that the patient tried and failed to have an adequate response to Tyruko (natalizumab‑sztn).
- Does not apply when the requested indication differs from Tyruko's.
Document Opdivo+Yervoy failure or Yervoy contraindication for Opdualag
Prior authorization for Opdualag new starts requires documentation of prior failure of Opdivo plus Yervoy, or a documented contraindication to Yervoy.
- Lack of trial or documented contraindication may cause denial.
Require generic paclitaxel trial before Abraxane (non‑pancreatic indications)
Prior authorization for Abraxane (for indications other than pancreatic cancer or small bowel carcinoma) requires documentation that the patient tried and failed to have an adequate response to generic paclitaxel.
- Does not apply when Abraxane is used for an indication not shared with generic paclitaxel.
Require Udenyca trial and failure before non‑preferred pegfilgrastim biosimilars/Ryzneuta
Prior authorization for non‑preferred pegfilgrastim biosimilars or Ryzneuta new starts requires documentation that the patient tried and failed to have an adequate response to Udenyca.
- Does not apply when indication is not shared with the preferred pegfilgrastim product.
Require prior pemetrexed trial for Axtle/Pemfexy/Pemrydi new starts
Prior authorization for Axtle (J9292), Pemfexy (J9304), or Pemrydi (J9324) new starts requires documentation that the patient tried and failed to have an adequate response to an allowed pemetrexed product (listed pemetrexed HCPCS codes), unless contraindicated or not tolerated.
- Requests will be denied if prior trial and failure of pemetrexed (listed HCPCS) are not documented for new starts (unless contraindicated or not tolerated).
Document pemetrexed trial and failure for Axtle/Pemfexy/Pemrydi RTU
For Axtle, Pemfexy, or Pemrydi RTU new starts, prior authorization requires documentation that the patient tried and failed pemetrexed (listed pemetrexed HCPCS codes) unless contraindicated or not tolerated.
- Absence of documented pemetrexed trial and failure may result in denial.
Intravitreal anti‑VEGF prior trial of bevacizumab (and second‑step when specified)
Prior authorization for intravitreal ranibizumab products or other listed intravitreal anti‑VEGF agents on new starts requires documentation that the patient tried and failed bevacizumab (Avastin); for certain agents an additional second‑step trial is required as specified.
- Step 1: bevacizumab (Avastin).
- Step 2 (for some agents): either Cimerli/ranibizumab‑eqrn or aflibercept, brolucizumab, or faricimab as specified for Byooviz, Lucentis, Susvimo (new starts only).
Medical prior authorization required for viscosupplements (billable to Medicare Part B)
Medical prior authorization is required for all viscosupplements; because they are medical devices they must be billed through Medicare Part B.
- For non‑preferred viscosupplements, documentation of trial and failure or intolerance to both preferred agents (Euflexxa and Synvisc‑One) is required for new starts.
Index entries—cross‑reference individual drug policies for PA rules
This index lists drugs alphabetically and does not itself specify prior authorization or step therapy rules; providers must cross‑reference the individual drug policy sections for the applicable PA rules.
- Use the product‑specific policy sections for submission and PA requirements.
Require bevacizumab (Avastin) trial before EYLEA/BEOVU for certain ophthalmic indications
For new ophthalmic angiogenesis inhibitor starts (EYLEA, BEOVU), prior authorization requires documentation that the patient tried and failed to have an adequate response to bevacizumab (Avastin) for the specified indications.
- Applies to neovascular AMD, diabetic macular edema, and other specified ophthalmic indications (new starts only).
Require IV gemcitabine trial before Avgemsi (shared oncology indications)
For Avgemsi new oncology starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to intravenous gemcitabine for shared indications.
- Does not apply to indications not shared with gemcitabine.
Require Treanda (J9033) trial before Belrapzo/bendamustine products
For Belrapzo and other bendamustine products, new starts require documentation that the patient tried and failed to have an adequate response to Treanda (J9033) unless contraindicated or not tolerated.
- Does not apply to indications not shared with Treanda.
Require Mvasi or Zirabev trial before certain oncology bevacizumab agents
For Alymsys, Avastin (oncology), Jobevne, or Vegzelma new oncology starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to Mvasi or Zirabev.
- Exemptions: ophthalmic Avastin uses and indications not shared with Mvasi/Zirabev.
Require emtricitabine/tenofovir intolerance or contraindication for Apretude
Apretude approval requires that the patient tried and had an intolerance to or has a contraindication to emtricitabine/tenofovir disoproxil fumarate prior to approval.
- This is a prerequisite for new starts.
Document failure of Botox and Xeomin before Myobloc
For Myobloc new starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to both Botox and Xeomin.
- Applies to new starts only.
Require Ocrevus trial and failure before Briumvi
For Briumvi new starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to Ocrevus.
- Applies to new starts only.
Require trial and failure of Eligard/Lupron or carboplatin as specified
For Camcevi new starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to Eligard (and for Kyxata the comparator is carboplatin); applies only when indications are shared with the comparator.
- Does not apply when the requested indication is not shared by the comparator.
Document prior biologic trial/failure for NMOSD and gMG biologics
For NMOSD and generalized myasthenia gravis new starts, prior authorization requires documentation of trial and failure, intolerance, or contraindication to the listed prior biologics (e.g., Enspryng and either Uplizna or rituximab for NMOSD; Vyvgart or Vyvgart Hytrulo for gMG).
- Documentation of prior trial/intolerance/contraindication is required for approval.
Require Ruxience or Riabni trial before Enjaymo
For Enjaymo new starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to Ruxience or Riabni (or another rituximab product).
- Applies to new starts only.
Document statin and PCSK9 inhibitor trial/contraindication for Evkeeza
For Evkeeza new starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to or has a contraindication to both a maximally‑tolerated statin and a PCSK9 inhibitor.
- Failure to document these prior therapies may trigger denial.
Require Hemlibra failure before Feiba
For Feiba new starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to Hemlibra.
- Does not apply to treatment of hemophilia B.
Require Cosentyx + one additional biologic trial for Ilumya
For Ilumya new starts, prior authorization requires documentation that the patient tried and failed to have an adequate response to the formulary‑preferred IL‑17 inhibitor (Cosentyx) and one listed on‑formulary biologic or infliximab/Remicade.
- Documentation of trial and inadequate response or intolerance to the preferred IL‑17 inhibitor and one other listed biologic is required.
Document prior cemiplimab regimen response/intolerance for Imjudo (NSCLC)
For Imjudo (NSCLC) new starts, prior authorization requires documentation that the patient had an adequate response to or intolerance/contraindication to regimens containing cemiplimab (Libtayo).
- Applies to the NSCLC indication (new starts only).
Coding and Billing
| Alymsys, Avastin, Jobevne, Vegzelma (Avastin ophthalmic exceptions apply) | |
| Mvasi and Zirabev (required step agents for oncology indications) | |
| J9035 | Bevacizumab (Avastin) - HCPCS example code (if applicable) |
| Products listed: Epogen (various strengths), Procrit (various strengths) |
| Byooviz 0.5 mg/0.05 mL intravitreal | |
| Cimerli 0.3 mg/0.05 mL intravitreal | |
| Cimerli 0.5 mg/0.05 mL intravitreal | |
| Lucentis 0.3 mg/0.05 mL intravitreal | |
| Lucentis 0.5 mg/0.05 mL intravitreal | |
| Susvimo implant/fill 10 mg/0.1 mL intravitreal | |
| Avastin (bevacizumab) — intravitreal use subject to step rules |
| Rituxan Hycela solution 1400-23400 mg - UT/11.7 mL subcutaneous | |
| Rituxan Hycela solution 1600-26800 mg - UT/13.4 mL subcutaneous | |
| Rituxan solution 500 mg/50 mL IV | |
| Truxima solution 100 mg/10 mL IV | |
| Truxima solution 500 mg/50 mL IV |
| Rystiggo solution 280 mg/2 mL subcutaneous | |
| Rystiggo solution 420 mg/3 mL subcutaneous | |
| Rystiggo solution 560 mg/4 mL subcutaneous | |
| Rystiggo solution 840 mg/6 mL subcutaneous |
| Rytelo solution reconstituted 188 mg IV | |
| Rytelo solution reconstituted 47 mg IV |
| Spinraza solution 12 mg/5 mL intrathecal | |
| Spinraza solution 28 mg/5 mL intrathecal | |
| Spinraza solution 50 mg/5 mL intrathecal |
| Tezspire solution prefilled syringe 210 mg/1.91 mL subcutaneous |
| Actemra solutions 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL IV | |
| Avtozma solutions 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL IV | |
| Tofidence solutions 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL IV |
| Herceptin Hylecta solution 600–10000 mg unit/5 mL subcutaneous | |
| Herceptin solution reconstituted 150 mg IV | |
| Herzessi solution reconstituted 150 mg and 420 mg IV | |
| Herzuma solution reconstituted 150 mg and 420 mg IV | |
| Ogivri solution reconstituted 150 mg and 420 mg IV | |
| Ontruzant solution reconstituted 150 mg and 420 mg IV | |
| Kanjinti and Trazimera (preferred comparators) |
Initial Therapy (New Starts) Criteria
inv-179: Myobloc initial therapy requirement
Required for Myobloc approval
inv-180: Rituximab biosimilars — New start requirement
New start requirement
inv-181: Evkeeza — New start requirement
New start requirement
inv-182: New start step therapy requirements — Initial therapy (new starts) rules
Initial therapy (new starts) rules
See product-specific durations/formulations.
Applies to new starts only.
Applies to new starts only.
Applies to new starts only.
Applies to new starts only.
Applies to new starts only.
Applies to new starts only.
Applies to new starts only.
inv-183: Initial therapy (selected)
Initial therapy requirements for select agents (new starts only):
inv-184: Herceptin initial therapy
Initial therapy requirements for new starts
Step Therapy Summary Table
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| EYLEA (aflibercept) / BEOVU (brolucizumab) and other specified intravitreal anti-VEGF agents | ||
| Patient must have tried and failed to have an adequate response to bevacizumab (Avastin). | ||
| Applies to new starts only; does not apply when the requested product is used for an off-label indication not shared with bevacizumab. For some agents a two-step sequence is specified (see policy). |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| AMVUTTRA | ||
| Patient must have tried and failed to have an adequate response to Onpattro. | ||
| Applies to new starts only. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| APHEXDA | ||
| Patient must have tried and failed to have an adequate response to plerixafor. | ||
| Applies to new starts only. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Asceniv (IVIG) | ||
| Patient must have tried and failed to have a response to another IVIG product. | ||
| Applies to new starts only; does not apply when Asceniv is used for an indication not shared with preferred IVIG products. |
| Drug / Product | Required prior therapy (new oncology starts) | Notes / Exceptions |
|---|---|---|
| Avgemsi | ||
| Patient must have tried and failed to have an adequate response to intravenous gemcitabine. | ||
| Applies to new oncology starts only; does not apply for indications not shared with gemcitabine. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Belrapzo / other bendamustine products | ||
| Patient must have tried and failed to have an adequate response to Treanda (J9033), unless contraindicated or not tolerated. | ||
| Applies to new starts only; does not apply to indications not shared with Treanda. |
| Drug / Product | Required prior therapy (oncology new starts) | Notes / Exceptions |
|---|---|---|
| Alymsys / Avastin (oncology) / Jobevne / Vegzelma | ||
| Patient must have tried and failed to have an adequate response to Mvasi or Zirabev. | ||
| Applies to oncology new starts only; does not apply to ophthalmic uses of Avastin or indications not shared with Mvasi/Zirabev. |
| Drug / Product | Required prior condition (new starts) | Notes / Exceptions |
|---|---|---|
| Apretude | ||
| Patient must have an intolerance to or a contraindication to emtricitabine/tenofovir disoproxil fumarate. | ||
| Requirement reflects condition for approval; applies to new starts only where specified. |
| Drug / Product | Required prior therapy (oncology new starts) | Notes / Exceptions |
|---|---|---|
| Alymsys / Avastin / Jobevne / Vegzelma | ||
| Patient must have tried and had an inadequate response to Mvasi or Zirabev before initiating these oncology bevacizumab agents. | ||
| Applies to new starts only; does not apply to ophthalmic indications or indications not shared with Mvasi/Zirabev. |
| Drug / Product | Required prior therapy (new oncology starts) | Notes / Exceptions |
|---|---|---|
| Docivyx (J9172) / Beizray (J9174) | ||
| Patient must have tried and failed to have an adequate response to docetaxel (J9171). | ||
| Applies to new oncology starts only. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Prolia / Xgeva / non-preferred denosumab biosimilars | ||
| For Prolia: patient must have tried and failed Bildyos or Jubbonti. For Xgeva: patient must have tried and failed Bilprevda or Wyost. | ||
| Applies to new starts only; does not apply when the non-preferred denosumab is used for an indication not shared with the specified preferred biosimilars. |
| Condition / Drug group | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Neuromyelitis optica spectrum disorder (NMOSD) | ||
| Patient must have tried and failed or had intolerance/contraindication to Enspryng and either Uplizna or rituximab. | ||
| Applies to NMOSD new starts only; required prior therapies are enumerated in policy. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Enjaymo | ||
| Patient must have tried and failed to have an adequate response to Ruxience or Riabni (or another rituximab product). | ||
| Applies to new starts only. |
| Drug group / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Rituximab-containing products (Ruxience / Riabni preferred) | ||
| Patient must have tried and failed to have an adequate response to Ruxience or Riabni (or another rituximab product). | ||
| Applies to new starts only; step does not apply when indication is not shared with the preferred rituximab products. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Epoetin alfa alternatives (Epogen / Procrit alternatives) | ||
| Patient must have tried and failed to have an adequate response to Retacrit. | ||
| Applies to new starts only; does not apply when Epogen/Procrit are used for indications not shared with Retacrit. |
| Drug group / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| G-CSF products (Filkri, Granix, Neupogen, Nivestym, Nypozi, Releuko) | ||
| Patient must have tried and failed to have an adequate response to Zarxio. | ||
| Applies to new starts only; does not apply when the non-preferred agent is used for an indication not shared with Zarxio. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Invega Hafyera (paliperidone palmitate long-acting injectable) | ||
| Documentation of at least 4 months' treatment with 1-month paliperidone palmitate extended‑release injectable suspension OR at least one 3‑month injection of 3‑month paliperidone palmitate is required. | ||
| This documentation is required for new starts only; policy specifies duration/formulation details. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Multiple non-preferred products and biosimilars (selected examples) | ||
| Patient must have tried and failed to have an adequate response to the specified preferred agent or biosimilar listed for each product (see policy for product-specific comparators). | ||
| Applies to new starts only; exceptions allowed for documented contraindication or intolerance. Specific J-codes and comparators are enumerated in the policy. |
| Step | Required agent(s) in sequence (new starts) | Applicable products / Notes |
|---|---|---|
| Step 1 | ||
| Bevacizumab (Avastin) | ||
| Step 1 applies to intravitreal anti-VEGF new starts; some agents require a Step 2 as described below (Byooviz, Lucentis, Susvimo). |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Axtle (J9292) / Pemfexy (J9304) / Pemrydi RTU (J9324) | ||
| Patient must have tried and failed to have an adequate response to pemetrexed (one of J9294, J9296, J9297, J9305, J9314, J9322, J9323), unless contraindicated or not tolerated. | ||
| Applies to new starts only; does not apply for indications not shared with preferred pemetrexed agents. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Rituxan / Rituxan Hycela / Truxima | ||
| Patient must have tried and failed to have an adequate response to Riabni or Ruxience. | ||
| Applies to new starts only; does not apply when indication is not shared with Riabni or Ruxience. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| (General entry for listed products) | ||
| Patient must have tried and failed to have an adequate response to the specified preferred comparator listed in the policy. | ||
| Applies to new starts only; see product-specific sections for precise comparators and documentation requirements. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Epoetin alfa alternatives (Epogen / Procrit alternatives) | ||
| Patient must have tried and failed to have an adequate response to Retacrit. | ||
| Applies to new starts only; does not apply when Epogen or Procrit is used for an indication not shared with Retacrit. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| G-CSF non-preferred agents | ||
| Patient must have tried and failed to have an adequate response to Zarxio. | ||
| Applies to new starts only; exception when indication is not shared with Zarxio. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Infliximab biosimilars (Avsola / Inflectra / Renflexis) | ||
| Patient must have tried and failed to have an adequate response to generic infliximab or Remicade. | ||
| Applies to new starts only; does not apply when the biosimilar is used for an indication not shared with generic infliximab/Remicade. |
| Drug / Product | Required documentation (new starts) | Notes / Exceptions |
|---|---|---|
| Invega Hafyera | ||
| Documentation of prior paliperidone palmitate treatment: at least 4 months of 1-month paliperidone palmitate OR at least one 3-month paliperidone palmitate injection. | ||
| Required for approval of listed Invega Hafyera strengths on new starts only. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Intravitreal ranibizumab products (Cimerli / ranibizumab-eqrn) and other intravitreal anti-VEGF agents (Byooviz, Lucentis, Susvimo) | ||
| Step 1: patient must have tried and failed bevacizumab (Avastin). For certain agents (Byooviz, Lucentis, Susvimo) Step 2 requires trial and failure of either Cimerli/ranibizumab-eqrn or aflibercept/brolucizumab/faricimab after bevacizumab. | ||
| Applies to shared ophthalmic indications on new starts only; see policy for step sequencing details and exceptions for non-shared indications. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Axtle / Pemfexy / Pemrydi RTU | ||
| Patient must have tried and failed to have an adequate response to pemetrexed (specified J-codes) unless contraindicated or not tolerated. | ||
| Applies to new starts only; documentation of contraindication/intolerance accepted where applicable. |
| Drug / Product | Required prior therapy (new starts) | Notes / Exceptions |
|---|---|---|
| Rituxan / Rituxan Hycela / Truxima | ||
| Patient must have tried and failed to have an adequate response to Riabni or Ruxience. | ||
| Applies to new starts only. |
Site of Care and Billing
Biosimilar and Comparator Requirements
Definitions
Background
Step therapy is a utilization management approach that requires patients to try preferred or lower‑cost medications first before coverage of alternative agents is approved. This policy lists specific Medicare Part B drugs and the required prior agent(s) for new therapy starts under Independent Health Medicare Advantage plans; many entries specify trial and inadequate response, intolerance, or documented contraindication to the preferred agent as the condition for approval.
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