Reminder: Effective Jan. 1, step therapy added for Medicare Part B drugs

Effective Jan. 1, 2019, Priority Health is adding step therapy requirements for a variety of Medicare Part B drugs (under the medical benefit) for new starts only. Specifically, we'll be adding step therapy to Part B drugs that currently have a prior authorization requirement in place.

What is step therapy

Step therapy requires a member to first try certain drugs to treat their medical condition before we'll cover another drug for that condition. For example, if Drug A and Drug B both treat a medical condition, we may not cover Drug B unless they try Drug A first. If Drug A does not work, we'll then cover Drug B.

All drugs with step therapy starting Jan. 1, 2019:

  • Aveed
  • Benlysta
  • Botox
  • Cinqair
  • Fasenra
  • Inflectta
  • Krystexxa
  • Nucala
  • Remicade
  • Renflexis
  • Rituxan
  • Soliris
  • Xeomin

Why we're adding step therapy

Step therapy ensures our members are getting the care they need at the right price. Drug costs affect all patients, including those with Medicare. Step therapy gives patients options that may save them money while still getting the care they need.

Impact to members

Members already receiving a drug will be exempt from the new step therapy requirement and will be able to continue on their current drug. If a member is coming from another health plan and was previously taking a drug on the step therapy required list, they are exempt, as they are not technically a new start to that drug. Step therapy requirements will not result in increased out-of-pocket cost to members, and we will follow current Part B exception request procedures.