Medicare step therapy proposed Jan. 1, 2019

Effective, Jan. 1, 2019, Priority Health Medicare is proposing adding step therapy requirements to the following Part B and Part D drugs:

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


In Aug. 2018, The Centers for Medicare and Medicaid Services (CMS) issued new guidance that allows Medicare Advantage (MA) plans may use step therapy for/with Part B drugs, beginning Jan. 1, 2019, as part of a patient-centered care coordination program.

In this guidance, CMS acknowledged that the use of step therapy is a recognized utilization management tool. The allowance of step therapy practices for/with Part B drugs will help achieve the goal of lower drug prices while maintaining access to covered services and drugs for beneficiaries.

What is step therapy?

Priority Health Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Priority Health Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Priority Health Medicare will then cover Drug B. For example, a member with Parkinson's Disease must first try carbidopa-levodopa ER before trying more costly drugs like Rytary™.

Impacted members

CMS has required that any new step therapy requirements not disrupt ongoing Part B/Part D drug therapies for members. Therefore, step therapy may only be applied to/with Part B drugs for members that are not actively receiving the affected medication. In other words, members already receiving a drug that will have a new step therapy requirement in 2019 will be able to continue on their current drug.

All MA plans were required to submit a list of proposed step therapy drugs/requirements to CMS by the end of August for approval, but Priority Health has not yet learned the CMS decision on these proposed step therapy requirements. Because we are still awaiting CMS and our Pharmacy and Therapeutics Committee's (P&T) approval, it's plausible that one or more of the proposed drug therapy changes may be denied by CMS or P&T, and therefore removed from the above list.

Additionally, step therapy requirements will not result in increased out-of-pocket cost to members, and we will follow current Part D exception request procedures.