Part B Drug Step Therapy
What’s step therapy and how does it work?
Just because something’s expensive doesn’t mean it’s the best. If you’re a smart shopper, you find an option that costs less and works just as well.
That’s the idea behind step therapy. We use it to make sure you’re getting the most effective and reasonably-priced drug available.
Your pharmacists or doctor may tell you that some medications may need step therapy. They will review your medical information to find the best and lowest cost medication that can treat your problem.
Step therapy is trying lower-priced medications before taking a step up to one that costs more. Before trying an expensive drug, we’ll check to see if you’ve tried lower-priced drug options.
If you don’t follow the procedure for step therapy when it’s required, the drug may cost you more, or may not be covered at all.
Part B Step Therapy Drugs
These are the drugs the are Part B, meaning they are paid under your medical benefits
| Drug Classes | Drug Name | Status | Billing Code |
|---|---|---|---|
| Ophtalmic Disorders | Avastin | Preferred | C9257, J9035 |
| Eylea | Non-Preferred | J0178 | |
| Lucentis | Non-Preferred | J2778 | |
| Macugen | Non-Preferred | J2503 | |
| Visudyne | Non-Preferred | J3396 | |
| Viscosupplements | Monovisc | Preferred | J7327 |
| Orthovisc | Non-Preferred | J7324 | |
| Durolane | Non-Preferred | J7318 | |
| Euflexxa | Non-Preferred | J7323 | |
| Gel-One | Non-Preferred | J7326 | |
| Gelsyn-3 | Non-Preferred | J7328 | |
| Genvisc 850 | Non-Preferred | J7320 | |
| Hylagan | Non-Preferred | J7321 | |
| Hymovis | Non-Preferred | J7322 | |
| Supartz | Non-Preferred | J7321 | |
| Supartz FX | Non-Preferred | J7321 | |
| Synvisc | Non-Preferred | J7325 | |
| Synvisc-One | Non-Preferred | J7325 | |
| TriVisc | Non-Preferred | J7329 | |
| Visco-3 | Non-Preferred | J7321 |
For providers: A trial and failure of the preferred drug must be documented before a non-preferred drug will be approved. All non-preferred drugs must be prior authorized. The preferred drugs do not require prior authorization.