Step therapy added for select Medicare Part B drugs effective Oct. 1, 2019

Priority Health added a step therapy requirement for a variety of Medicare Part B drugs on Jan. 1, 2019 following guidance from the Centers for Medicare and Medicaid Services (CMS). Effective Oct. 1, 2019, additional Medicare Part B drugs will be added to the step therapy requirement list for Medicare Advantage members who are starting the drug for the first time. 

Drugs with step therapy for new starts, starting Oct. 1, 2019:

  • Actemra
  • Cinryze
  • Dalvance
  • Entyvio
  • Iluvien, Retisert & Yutiq
  • Makena
  • Nulojix
  • Orencia
  • Parsabiv
  • Prolia
  • Signifor
  • Simponi Aria
  • Sivextro
  • Stelara
  • Supprelin LA
  • Testopel
  • Xgeva

What is step therapy? 

Step therapy requires a member to first try certain drugs to treat their medical condition before we'll cover another drug for that condition. For example, if Drug A and Drug B both treat a medical condition, we may not cover Drug B unless they try Drug A first. If Drug A does not work, we'll then cover Drug B.

Why are we adding step therapy?

Step therapy ensures our members are getting the care they need at the right price. Drug costs affect all patients, including those with Medicare. Step therapy gives patients options that may save them money while still getting the care they need.

What you need to do

After Oct. 1, 2019, prior to prescribing a new start for a medication that requires step therapy, you must first receive prior authorization and proceed through the required steps.

Currently, we do not have a prior authorization requirement in place under Medicare Part B for the above drugs. However, most of the drugs on this list already have a prior authorization requirement under commercial and under Medicare Part D. We will update our prior authorization forms on the provider manual on Oct. 1, 2019, to account for the above changes. 

Impact to members

Members already receiving a drug on the step therapy required list will be exempt from the new step therapy requirement and will be able to continue their current drug. If a member is coming from another health plan and was previously taking a drug on this list, they are exempt, as they are not technically a new start to that drug.

Step therapy requirements will not result in increased out-of-pocket cost to members, and we will continue to follow current Part B exception request procedures.

History

In Aug. 2018, The Centers for Medicare and Medicaid Services (CMS) issued new guidance that allows Medicare Advantage (MA) plans may use step therapy for/with Part B drugs, beginning Jan. 1, 2019, as part of a patient-centered care coordination program.

In this guidance, CMS acknowledged that the use of step therapy is a recognized utilization management tool. The allowance of step therapy practices for/with Part B drugs will help achieve the goal of lower drug prices while maintaining access to covered services and drugs for beneficiaries.