Some medical benefit drugs for Medicare Advantage members need step therapy, starting Jan. 1

In the new year, according to Centers for Medicare & Medicaid Services’ guidance, certain Medicare Part B specialty drugs will have additional step therapy authorization requirements. This will apply to Medicare Plus Blue^SM PPO and BCN Advantage^SM members for dates of service on or after Jan. 1, 2019.

Step therapy is treatment for a medical condition that starts with the most preferred drug therapy and progresses to other drug therapies only if necessary. The goal of step therapy is to encourage better clinical decision-making.

Some examples of drugs that require step therapy are:

• Botox^® for migraines and over active bladder
• Eylea^®, Lucentis^® and Macugen^® for neovascular age-related macular edema
• Prolia^® for osteoporosis

What’s changing?
For drugs requiring step therapy, authorization request questions will be different from the ones you currently answer.

Use NovoLogix^® to submit authorization requests
We encourage you to send prior authorization requests for Medicare Part B specialty drugs through the NovoLogix web tool via Provider Secured Services. It’s the most efficient way to get a determination.