Step therapy requirements for Medicare outpatient (Part B) medications

Security Health Plan requires step therapy for people who are prescribed any of the drugs listed in the table below for the first time. Step therapy, prior authorization and any related peer-to-peer reviews will be managed through our specialty pharmacy medication partner, Prime Therapeutics Management ((800) 424-8243 , https://primetherapeutics.com/).

Step therapy is the process of trying lower-priced drugs before taking a “step up” to one that is more expensive, in an effort to reduce the cost of care. Step therapy is a type of utilization management; others include prior authorization and quantity limits. 

Medicare requires health plans to establish a utilization management committee, as explained by Prime Therapeutics Management  in this article, Medicare Part B Utilization Management Committee Review. Further information about utilization management is offered in this article, Medicare Part B Utilization Management in the Absence of NCD or LCD.

On behalf of Security Health Plan, Prime Therapeutics Management manages two drug lists:

• Medical prior authorization and claims edits
• Post-service claim edits

Step Therapy will be required for the medications listed on the Step therapy requirements for Medicare outpatient (Part B) medications list.

Step therapy does not apply to patients using a non-preferred product if an indication is not shared by the preferred product or is not supported by treatment guidelines or clinical literature.