CurrentProvidence Health PlanPolicy N/A

Providence Medicare Advantage Plans 2026 Step Therapy Criteria for Part B Drugs (drug list / step therapy protocols)

Lists Medicare Part B medications subject to the plan's step therapy requirements and notes general rules for step therapy, prior authorization, and exemptions (e.g., prior use within 365 days). Each listed drug includes HCPCS/J-codes and links to individual policy criteria; some entries list an effective date if after 1/1/2026.

Policy Summary

PayerProvidence Health Plan

PolicyProvidence Medicare Advantage Plans 2026 Step Therapy Criteria for Part B Drugs (drug list / step therapy protocols)

Policy CodePolicy N/A

Change TypeClarified — drug list and effective-date flags

Effective Date

Next Review Date

Key ActionWhen requesting authorization for Step 2 or Step 3 drugs, provide prior-therapy documentation or clinical rationale showing failure/intolerance of prior steps or evidence of prior use within 365 days.

POLICY UPDATE CHANGES

Document lists the Medicare Part B drugs subject to step therapy and explains general rules including 365-day prior-use exemption and requirement for prior authorization for Step 2 and Step 3 drugs.

~230Number of listed drugs (approximate)

365 daysPrior-use exemption window

Summary of changes and at-a-glance stats

Providence Medicare Advantage Plans maintains a consolidated step therapy protocol for Medicare Part B–administered drugs that requires trial of a Step 1 (preferred) agent before covering Step 2/Step 3 (non‑preferred) agents; the list applies to Medicare Part B medications and links each HCPCS/J‑code to its individual policy criteria. There is a 365‑day prior‑use exemption (the step requirement does not apply if the member received the non‑preferred drug within the past 365 days), and step requirements integrate with prior authorization and quantity limits (Step 2 and Step 3 always require prior authorization; Step 1 usually does unless noted).

General step therapy rules and definitions

Step 1: Preferred drug—may require prior authorization (usually requires prior authorization unless the list indicates otherwise).

Step 2 / Step 3: Non‑preferred drugs—always require prior authorization and documentation showing failure/intolerance of prior steps or evidence of prior use within the past 365 days (Step 3 typically requires prior trial of Step 1 and Step 2).

HCPCS / J-codes for listed Part B medications

Listed Part B medications subject to step therapy (HCPCS/J-codes and other codes)mixed

J3262	Actemra (Tocilizumab)
J0791	Adakveo (Crizanlizumab-tmca)
J7173	Alhemo (Concizumab-mtci)
J1552	Alyglo (Immune globulin, gamma(IGG)- stwk)
Q5126	Alymsys (Bevacizumab-maly)
J1554	Asceniv (Immune globulin)
J9035	Avastin (Bevacizumab)
J3145	Aveed (Testosterone undecanoate)
Q5121	Avsola (Infliximab-axxq)
Q5156	Avtozma (Tocilizumab-anoh) - effective 2026-02-01

1–10 of 126

1/13

Each listed HCPCS/J‑code on the drug list links to its individual policy criteria; some code entries also include an “Effective Date (if after 1/1/2026)” field (for example Q5156, Q5134, and Yimmugo are noted with 2/1/2026 effective dates).

What providers must do

Prior Authorization

Prior authorization required for Step 2 and Step 3 drugs

Step 2 and Step 3 drugs always require prior authorization with documentation explaining failure/intolerance of prior steps or prior use within 365 days; Step 1 drugs usually require prior authorization unless otherwise noted in the list.

Step 2 and Step 3 always require PA; Step 1 usually requires PA unless noted in the list.

Documentation Required

Documentation for step exceptions

Providers must supply clinical rationale for why prior steps failed or are not tolerated, why the requested drug is medically necessary, or evidence of prior use within the past 365 days when requesting authorization.

Clinical rationale for failure/intolerance of prior steps
Why the requested drug is medically necessary for the member
Evidence showing prior use of the non-preferred drug within the past 365 days

Providers should note that drugs subject to step therapy may also be subject to separate quantity limits and that step therapy can bridge Part B and Part D drugs (a Part B drug may require prior trial of a Part D drug and vice versa).

Quantity limits and notable effective-date entries

Quantity limits can apply to both preferred and non‑preferred drugs; such limits are enforced through the plan’s separate policy entries even when a drug is on the step therapy list.

Code	Drug	Effective date	Note
Q5156	Avtozma (Tocilizumab-anoh)	2/1/2026	Listed with an effective date after 1/1/2026
Q5134	Tyruko (Natalizumab-sztn)	2/1/2026	Listed with an effective date after 1/1/2026
J1553	Yimmugo (Immune globulin (IgG)-dira human)	2/1/2026	Listed with an effective date after 1/1/2026

Document changes

2026-05-01clarified (is_material=false)Latest

Document lists the Medicare Part B drugs subject to step therapy and explains general rules including 365-day prior-use exemption and requirement for prior authorization for Step 2 and Step 3 drugs. Multiple drugs have 'Effective Date (if after 1/1/2026)' fields; a few entries show effective dates (e.g., Q5156 2026-02-01; Q5134 2026-02-01; Yimmugo 2026-02-01).