Medicare Part B outpatient medication coverage and step therapy
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Governs coverage and prior authorization / step therapy expectations for outpatient medications billed under Medicare Part B for Quartz Medicare Advantage members; applies to providers who administer clinic-based Part B drugs and to PA processes used by the plan.
No material clinical or coverage changes in this revision.
Coverage and Prior Authorization Rules
General coverage rule
Covered when ALL of the following are met:
Quartz Medicare Advantage Part B prior authorization criteria are posted at QuartzBenefits.com/MAPartBPA.
Per-product step therapy designations — Drug-specific step therapy status (examples)
Examples of how step therapy is represented for specific products (consult the table for each product's designation):
When step therapy is indicated, prior authorization will require documentation of prior trial and failure, or a qualifying contraindication or intolerance to preferred agents as specified by the plan.
Medications not listed in this document should be evaluated using external coverage resources. Providers and reviewers should consult the Medicare Coverage Database, the National Coverage Determinations (NCD) Report, and the Quartz Medicare Advantage Part B Prior Authorization page to determine applicable coverage rules and any plan‑specific prior authorization requirements.
Actions Required by Providers
Prior authorization required when step therapy applies
When the Step therapy column for a medication indicates step therapy, prior authorization is required. The prior authorization must include documentation of the required trials or qualifying reason (history of trial and failure, contraindication, or intolerance to a preferred medication) as specified by the plan.
- PA required when Step therapy = Yes in the table
- PA must document trial-and-failure, contraindication, or intolerance to preferred agent(s)
Step therapy applies to listed Part B drugs and requires documented trials
Step therapy is applied to specific Part B medications listed in the table; when step therapy is indicated providers must demonstrate a history of trial and failure (or documented contraindication or intolerance) of preferred agents as part of the prior authorization.
- Consult the table for each product’s step therapy designation (Step therapy = Yes means requirement applies)
- Required evidence: history of trial and failure, or contraindication/intolerance to preferred medication(s)
Document and follow applicable Medicare and Quartz PA criteria
Follow any applicable Medicare NCDs, LCDs, and LCAs where they exist; when Medicare guidance is absent, use Quartz’s Medicare Advantage Part B prior authorization criteria available at QuartzBenefits.com/MAPartBPA. Documentation submitted with PA requests must align with these references.
- Adhere to applicable NCDs/LCDs/LCAs for coverage determinations
- If no Medicare guidance exists, use Quartz MA Part B PA criteria posted at QuartzBenefits.com/MAPartBPA
- Include documentation consistent with Medicare guidance or Quartz PA criteria when submitting authorizations
Missing PA or step-therapy documentation may lead to denial
Failure to obtain required prior authorization or to provide evidence of required step therapy (trial and failure, contraindication, or intolerance) may result in claim denial when step therapy is required.
- Lack of required PA or missing documentation of step-therapy trials/qualifying reasons can lead to coverage denial
Definitions and Scope
This document lists outpatient, clinic‑administered drugs billed under Medicare Part B and explains how Quartz aligns coverage with existing Medicare guidance. Where a Medicare NCD/LCD/LCA exists for a medication, that determination must be followed. In the absence of Medicare local coverage guidance, Quartz may apply its own Part B prior authorization criteria consistent with Medicare Advantage plan allowances; plan‑specific prior authorization requirements and step therapy designations are posted on the Quartz Medicare Advantage Part B PA page.
When the table indicates step therapy for a medication, providers must complete the required steps and obtain prior authorization. The prior authorization must document a history of trial and failure, or a qualifying contraindication or intolerance, to the preferred medication(s) as specified by the plan.
Step Therapy Table and Operational Rules
| Rule | Explanation / provider action | PA documentation required |
|---|---|---|
| 3 = Yes (Step therapy required) | ||
| Step therapy must be completed before coverage; prior authorization is required when the Step therapy column for a medication indicates step therapy. | ||
| PA must include documentation of prior trials and failures of preferred agents, or documentation of a contraindication or intolerance to preferred agents as specified by the plan. |
Coding and References
| Medicare Coverage Database | Search for applicable coverage policies in the Medicare Coverage Database. |
| National Coverage Determination (NCD) Report | Refer to the National Coverage NCD Report for Medicare coverage determinations. |
| Quartz Medicare Advantage Part B Prior Authorization page | Quartz’s online Part B prior authorization guidance available at QuartzBenefits.com/MAPartBPA (referenced as the Quartz Medicare Advantage Part B Prior Authorization page). |
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