Medicare Part B Step Therapy

What is Medicare Part B Step Therapy?

Some medically administered Part B drugs, like injectables or biologics, may have special requirements or coverage limits, such as step therapy.
Step therapy requires a trial of a preferred drug to treat a medical condition before covering a non-preferred drug.

Here’s an example: Drug A (preferred) and Drug B (non-preferred) are both used to treat the same medical condition. We may require that you try Drug A (preferred) first. If Drug A does not work, we’ll then cover Drug B (non-preferred).

The step therapy requirement does not apply to members who have already received treatment with the non-preferred drug within the past 365 days.
Both preferred and non-preferred drugs may still be subject to prior authorization or quantity limits.

Click Here to Download the 2023 Medicare Part B Step Therapy Drug List.

Click Here to Download the 2022 Medicare Part B Step Therapy Drug List.

This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

Health benefits or health benefit administration may be provided by or through Highmark Wholecare, coverage by Gateway Health Plan, an independent licensee of the Blue Cross Blue Shield Association (“Highmark Wholecare”). Highmark Wholecare offers HMO plans with a Medicare Contract. Enrollment in these plans depends on contract renewal.

Medicare Ombudsman Website Best Available Evidence

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