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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 will be managed through our specialty pharmacy medication partner, Magellan (1-800-424-8243, spcustomer.magellanprovider.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 will be required for the medications listed in the table below provided the following are met:

Requested Product

Preferred Alternative Agent(s)

Go-live date

Special Comments

Epogen/Procrit (J0885)

Retacrit (Q5106)

5/1/2019

N/A

Eylea(J0178), Lucentis (J2778),

Macugen (J2503)

Avastin – ophthalmic use only (C9257)

5/1/2019

Patient must try and have an inadequate response, contraindication, or intolerance to an adequate trial of bevacizumab in EITHER EYE prior to consideration of a non-preferred product.

Beovu (J0179)

Avastin – ophthalmic use only (C9257)

4/1/2020

Patient must try and have an inadequate response, contraindication, or intolerance to an adequate trial of bevacizumab in EITHER EYE prior to consideration of a non-preferred product.

Neupogen (J1442), Nivestym (Q5110)

Granix (J1447), Zarxio (Q5101)

4/1/2020

N/A

Aloxi (J2469)

Kytril (J1626), Zofran (J2405)

4/1/2020

Step therapy requirements DO NOT APPLY to chemotherapy regimens considered highly emetogenic.

Avastin – for oncology indications only (J9035)

Mvasi (Q5107), Zirabev (Q5118)

4/1/2020

Step therapy requirements DO NOT APPLY to the follow FDA-approved indications:

  • Metastatic colorectal cancer:
    • In combo w/ intravenous fluorouracil-based chemo for 2nd-line treatment.
    • In combo w/ fluoropyrimidine- irinotecan- or fluoropyrimidine-oxaliplatin-based chemo for 2nd-line treatment in patients who have progressed on a 1st-line Avastin-containing regimen.

Fusilev (J0641), Khapzory (J0642)

Leucovorin (J0640)

4/1/2020

N/A

Herceptin (J9355)

Ontruzant (Q5112), Herzuma (Q5113), Ogivri (Q5114), Trazimera (Q5116), Kanjinti (Q5117)

4/1/2020

N/A

Requested Product

Preferred Alternative Agent(s)

Go-live date

Special Comments

Herceptin Hylecta (J9356)

Ontruzant (Q5112), Herzuma (Q5113), Ogivri (Q5114), Trazimera (Q5116), Kanjinti (Q5117)

4/1/2020

N/A

Rituxan (J9312)

Truxima (Q5115), Ruxience

4/1/2020

Step therapy requirements DO NOT APPLY to the following FDA-approved indications:

  • Non-Hodgkin’s Lymphoma (NHL):
    • Follicular, CD-20 positive, B-cell NHL in patients achieving a complete or partial response to a rituximab product in combo w/ chemo, as single-agent maintenance therapy.
    • Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after 1st-line cyclophosphamide, vincristine, and prednisone (CVP) chemo.
  • Rheumatoid Arthritis (RA) in combination with methotrexate in adult patients with moderately to severely-active RA who have inadequate response to one or more TNF antagonist therapies.

Rituxan Hycela (J9311)

Truxima (Q5115), Ruxience

4/1/2020

Step therapy requirements DO NOT APPLY to the following FDA-approved indications:

  • Non-Hodgkin’s Lymphoma (NHL):
    • Follicular, CD-20 positive, B-cell NHL in patients achieving a complete or partial response to a rituximab product in combo w/ chemo, as single-agent maintenance therapy.
    • Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after 1st-line cyclophosphamide, vincristine, and prednisone (CVP) chemo.

Sustol (J1627)

Aloxi (J2469), Kytril (J1626), Zofran (J2405)

4/1/2020

N/A

Treanda (J9033)

Belrapzo (J9036), Bendeka (J9034)

4/1/2020

Step therapy requirements DO NOT APPLY to the following FDA-approved indications:

  • Indolent B-cell non-Hodgkin lymphoma (NHL) that has progressed during or within 6 months of treatment with rituximab or a rituximab-containing regimen.

Xgeva (J0897)

Zoledronic acid (J3489)

4/1/2020

Step therapy requirements DO NOT APPLY to the following FDA-approved indications:

  • Hypercalcemia of malignancy
  • Skeletal-related events in patients with bone metastases from metastatic breast and metastatic castration-resistant prostate cancers

Zilretta (J3304)

Kenalog (J3301)

4/1/2020

N/A

Ziextenzo (J3590)

Neulasta (J2505), Udenyca (Q5111), Fulphila (Q5108)

7/1/2020

N/A