Effective 1/1/24: Medicare and MMP Part B Step Therapy
Date: 11/30/23
Step Therapy programs are developed by Wellcare By Allwell and STAR+PLUS Medicare-Medicaid Plan (MMP) P&T Committees. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.
Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.
The first-line drugs on the Wellcare and MMP formulary have been evaluated through the use of clinical literature and are approved by the P&T Committees. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on the list.
Drugs requiring step therapy effective January 01, 2024, are listed below. Please note:
- The prescriber, patient, or authorized representative may ask for an exception.
- Step therapy applies if the drug has not been used in the past 365 days.
Drug Name |
|---|
Abatacept (Orencia®) |
Ado-trastuzumab emtansine (Kadcyla®) |
Aflibercept (Eylea®) |
Atezolizumab (Tecentriq®) |
Axicabtagene ciloleucel (Yescarta®) |
Bevacizumab (Avastin®, Alymsys®, Mvasi®, Vegzelma™, Zirabev™) |
Brentuximab vedotin (Adcetris®) |
Brexucabtagene autoleucel (Tecartus™) |
Brolucizumab-dbll (Beovu®) |
Cemiplimab-rwlc (Libtayo®) |
Certolizumab (Cimzia®) |
Ciltacabtagene autoleucel (Carvykti™) |
Corticosteroid intravitreal implants: dexamethasone (Ozurdex®), fluocinolone acetonide (Iluvien®, Retisert®, Yutiq™) |
Corticotropin (H.P. Acthar®, Purified Cortrophin™ Gel) |
Daratumumab (Darzalex®), daratumumab/hyaluronidase-fihj (Darzalex Faspro™) |
Darbepoetin alfa (Aranesp®) |
Denosumab (Xgeva®) |
Durvalumab (Imfinzi®) |
Eflapegrastim-xnst (Rolvedon™) |
Elotuzumab (Empliciti®) |
Emapalumab-lzsg (Gamifant™) |
Epoetin alfa (Epogen®, Procrit®) |
Faricimab-svoa (Vabysmo™) |
Ferric carboxymaltose (Injectafer®) |
Ferric derisomaltose (Monoferric®) |
Ferric pyrophosphate (Triferic®, Triferic Avnu®) |
Ferumoxytol (Feraheme®) |
Filgrastim (Neupogen®, Zarxio®, Nivestym™, Granix®, Releuko®) |
Golimumab (Simponi®, Simponi Aria®) |
Hyaluronate derivatives: sodium hyaluronate (Euflexxa®, Gelsyn-3™, GenVisc®850, Hyalgan®, Supartz FX™, Synojoynt™, Triluron™, TriVisc™, VISCO-3™), hyaluronic acid (Durolane®), cross-linked hyaluronate (Gel-One®), hyaluronan (Hymovis®, Orthovisc®, Monovisc®), hylan polymers A and B (Synvisc®, Synvisc One®) |
Idecabtagene vicleucel (Abecma™) |
Immune globulins (Asceniv™, Bivigam®, Cutaquig®, Cuvitru™, Flebogamma® DIF, GamaSTAN®, GamaSTAN® S/D, Gammagard® liquid, Gammagard® S/D, Gammaked™, Gammaplex®, Gamunex®-C, Hizentra®, HyQvia®, Octagam®, Panzyga®, Privigen®, Xembify®) |
IncobotulinumtoxinA (Xeomin®) |
Lisocabtagene maraleucel (Breyanzi®) |
Lurbinectedin (Zepzelca™) |
Luspatercept-aamt (Reblozyl®) |
Lutetium Lu 177 dotatate (Lutathera®) |
Nadofaragene firadenovec-vncg (Adstiladrin®) |
Natalizumab (Tysabri®) |
Nivolumab (Opdivo®) |
Pegfilgrastim (Neulasta®, Fulphila™, Fylnetra®, Nyvepria™, Stimufend®, Udenyca™, Ziextenzo™) |
Pembrolizumab (Keytruda®) |
Polatuzumab vedotin-piiq (Polivy™) |
Ramucirumab (Cyramza®) |
Ranibizumab (Lucentis®, Byooviz®, Cimerli™, Susvimo™) |
RimabotulinumtoxinB (Myobloc®) |
Rituximab (Rituxan®, Riabni™, Ruxience™, Truxima®), rituximab/hyaluronidase (Rituxan Hycela™) |
Romiplostim (Nplate®) |
Romosuzumab-aqqg (Evenity™) |
Sargramostim (Leukine®) |
Sipuleucel-T (Provenge®) |
Teclistamab-cqyv (Tecvayli®) |
Teprotumumab-trbw (Tepezza™) |
Tisagenlecleucel (Kymriah®) |
Tocilizumab (Actemra®) |
Trastuzumab (Herceptin®, Ontruzant®, Herzuma®, Ogivri™, Trazimera™, Kanjinti™), trastuzumab/hyaluronidase (Herceptin Hylecta™) |
Triamcinolone ER injection (Zilretta®) |
Triamcinolone acetonide suprachoroidal injection (Xipere™) |
Vedolizumab (Entyvio®) |
Verteporfin (Visudyne®) |