Part B Step Therapy

{{planProfile.planTypeName}}

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 may continue using the non-preferred drug.

Drugs listed in the “Non-Preferred Drug Products” column below may be subject to Step Therapy when administered for the first time:

In Scope Drug Category	Non-Preferred Drug Products	Preferred Drug Products
Anemia (intravenous iron replacement)	Feraheme Injectafer Monoferric	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	Mvasi* Zirabev*
Bone Density Agents for Oncology	Prolia Xgeva	Ibandronate Pamidronate Zoledronic Acid
Bone Density Agents for Osteoporosis	Evenity Prolia	Alendronate Ibandronate Risedronate 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 (J9217)*
Gout Agents	Krystexxa	Allopurinol Febuxostat
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*
Inflammatory Conditions (such as Rheumatoid Arthritis)	Infliximab Remicade Renflexis		Inflectra Avsola
Leucovorin/Levoleucovorin	Fusilev Khapzory Levoleucovorin		Leucovorin*
Lupus Agents	Saphnelo		Benlysta
Nebulizer Solutions (dispensed at a pharmacy)	Brovana		Perforomist
Orthopedic Joint Lubricant (Medical Device)	Euflexxa, Gel-One, Genvisc 850, Hyalgan,	Supartz, Supartz FX Synojoynt, Triluron, TriVisc, Visco-3	Durolane Gelsyn-3 Synvisc/Synvisc-One
Red Blood Cell Generation	Epogen Procrit		Retacrit
Rituximab Products (for both cancer and non-cancer conditions)	Riabni Rituxan Rituxan Hycela		Ruxience* Truxima*
Trastuzumab Products	Herceptin Herceptin Hylecta Herzuma Ogivri Ontruzant		Kanjinti* Trazimera*
Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Age Related Macular Degeneration)	Beovu Byooviz 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 Lucentis Susvimo Vabysmo		Eylea
White Blood Cell Generation (Short Acting)	Granix Neupogen Nivestym Relueko		Zarxio*
White Blood Cell Generation (Long Acting)	Fulphilia Fylnetra Udenyca Nyvepria		Neulasta* Ziextenzo*

*No prior authorization is required for Preferred Drug Products with the following exceptions:

1. Drug is used for a cancer diagnosis

2. Drug is an Immune Globulin

Only certain plans will require Step Therapy for these drugs. If you are receiving one of these drugs, please contact the customer service center at the phone number on the back of your ID card to determine if your plan is in scope.