Group Part B Step Therapy

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Drugs that are injected or infused by your physician in their office, or in a hospital outpatient or ambulatory surgical center are typically covered under your medical (Part B) benefit. Some Part B drugs may require step therapy. Step therapy means that a preferred drug must be tried before a non-preferred drug will be approved by your plan. If you have already been on a non-preferred drug in the previous 365 days, you will not be required to switch to a preferred product, and you may continue using the non-preferred drug.

In Scope Drug Category	Non-Preferred Drug Products	Preferred Drug Products
Anemia (intravenous iron replacement)	Injectafer Monoferric	Feraheme Ferrlecit INFed Venofer
Anti-Nausea Products for Oncology (specifically when used as part of a chemotherapy regimen)	Akynzeo Cinvanti Sustol	Aloxi Emend† Granisetron (Kytril) Ondansetron (Zofran)
Bevacizumab Products (for cancer conditions only)	Alymsys Avastin Avzivi	Mvasi† Zirabev†
Bone Density Agents for Oncology	Prolia Xgeva	Ibandronate Pamidronate Zoledronic Acid
Bone Density Agents for Osteoporosis	Evenity Prolia	Ibandronate Pamidronate Zoledronic Acid
Gemcitabine	Infugem (J9198)	Gemcitabine (J9201)†
Gonadotropin Releasing Hormone Analogs for Oncology	Leuprolide Acetate 3.75 mg (J1950)	Leuprolide Acetate 7.5 mg (J1954, J9217)†
Immune Globulins	Asceniv Cutaquig Panzyga	Bivigam† Carimune NF† Cuvitru† Flebogamma DIF† Gammagard† Liquid† Gammagard S/D† Gammaked† Gammaplex† Gamunex-C† Hizentra† HyQvia† Octagam† Privigen† Xembify†
Immunotherapy for certain cancers - Head and Neck	Keytruda Opdivo	Loqtorzi†
Immunotherapy for certain cancers - Non-Small Cell Lung Cancer	Opdivo plus Yervoy	Keytruda† Libtayo† Tecentriq†
Inflammatory Conditions - Infliximab	Infliximab Inflectra Remicade	Avsola Renflexis
Inflammatory Conditions -Tocilizumab	Actemra	Tofidence Tyenne
Leucovorin/Levoleucovorin	Fusilev Khapzory Levoleucovorin	Leucovorin†
Lupus Agents	Saphnelo	Benlysta
Orthopedic Joint Lubricants	Euflexxa, Gel-One, Genvisc 850, Hyalgan, Supartz, Supartz FX Synojoynt, Triluron, TriVisc, Visco-3	Durolane Gelsyn-3 Synvisc/Synvisc-One
Rituximab Products (for both cancer and non-cancer conditions)	Riabni Rituxan Rituxan Hycela	Ruxience† Truxima†
Trastuzumab Products	Herceptin Herceptin Hylecta Hercessi Herzuma Ogivri Ontruzant	Kanjinti† Trazimera†
Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Age Related Macular Degeneration)	Beovu Byooviz Cimerli Eylea HD Lucentis Susvimo Vabysmo	First: Compounded Avastin (bevacizumab) Then: Eylea†
Vascular Endothelial Growth Factor (VEGF) Inhibitors (for conditions other than Age Related Macular Degeneration)	Beovu Byooviz Cimerli Eylea HD Lucentis Susvimo Vabysmo	Eylea†
White Blood Cell Generation (Short Acting)	Granix Neupogen Nivestym Nypozi Relueko	Zarxio†
White Blood Cell Generation (Long Acting)	Fulphilia Fylnetra Nyvepria Rolvedon Stimufend Ziextenzo	Neulasta* Rolvedon*

*No prior authorization is required for preferred drug products unless the product is marked with a (†) indicating prior authorization is required.

Only certain plans will require step therapy for these Part B drugs.  If you are using one of these drugs under the Part B benefit, please contact the customer service center at the phone number on your member ID card to determine if your plan is in scope.