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.

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 Vegzelma		Mvasi† Zirabev†
Bone Density Agents for Oncology	Prolia Xgeva		Alendronate Ibandronate Pamidronate Risedronate 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 (J1954, J9217)†
Gout Agents	Krystexxa		Allopurinol Febuxostat
Immune Globulins	Alyglo Asceniv Cutaquig Panzyga		Bivigam† 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†
Lipid Lowering Agents	Leqvio		Praluent Repatha
Lupus Agents	Saphnelo		Benlysta
Migraine Therapy	Vyepti		Aimovig Ajovy Emgality
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 Eylea HD Relueko		Zarxio†
White Blood Cell Generation (Long Acting)	Fulphilia Fylnetra Nyvepria Rolvedon Stimufend Ziextenzo		Neulasta† Udenyca†

*No prior authorization for Part B coverage 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 drugs. If you are receiving one of these drugs, please contact the customer service center at the phone number on your member ID card to determine if your plan is in scope.