MA Part B Step Therapy for Outpatient Medications Policy Number M.18

Medical benefit drug policies are a source for Blue Cross and Blue Shield of Nebraska Medicare Advantage medical policy information only. These documents are not to be used to determine benefits or reimbursement. Please reference the appropriate certificate or contract for benefit information. This policy may be updated and therefore subject to change. 
 
Policy Number M.18 
MA Part B Step Therapy for Outpatient Medications 
Effective 01/01/2025

Codes Applied to Policy

Policy

Step Therapy will be required for the medications listed in the table below provided the following are met: 

1. The requested product meets the definition of a Medicare outpatient (Part B) drug; AND 
2. The proposed use of the requested product has been determined to be a medically accepted indication; AND 
3. The proposed use of the preferred alternative agent has been determined to be a medically accepted indication; AND 
4. The dose, frequency and duration of use may not exceed the safety and efficacy data supporting the medically accepted indication; AND 
5. Patient is considered a new start to the non-preferred product (defined as no use in the previous 365 days) AND 
6. The requested product is necessary for treating the enrollee's condition as the preferred drug(s) has(have) been or is(are) likely to be less effective or have adverse effects; AND 
7. When there are multiple preferred drugs, unless otherwise specified, only one is required prior to approval of the non-preferred drug.