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Dec 1, 2021

Step therapy drug update for Medicare – Effective January 1, 2022

Beginning January 1, 2022, the below list of drugs will require step therapy for Medicare members as part of medical drug review. There are also nine drugs that as of January 1, 2022 will require prior authorization (PA) for the first time but will also have step therapy.

 

  • Will require documentation of trial and failure of Kanjinti and Trazimera (PA already exists):

J9355         Herceptin

 

  • Will require documentation of trial and failure of Truxima and Riabni (PA already exists):

J9312         Rituxan

Q5119       Ruxience

J9310         Rituximab

 

  • Will require documentation of trial and failure of Avastin, Mvasi, and Zirabev (PA already exists):

J0178         Eyelea

J0179         Beovu

J2778         Lucentis

 

  • Will require documentation of trial and failure of Zoledronic acid (PA already exists):

J0897         Xgeva

J0897         Prolia

 

  • Will require documentation of trial and failure of Euflexxa, Orthovisc, and Durolane (PA required as of January 1, 2022):

J7327         Monvisc

J7325         Synvisc

J7321         Hyalgan

J7328         Gelsyn

J7321         Supartz

J7320         Genvisc

J7329         Trvisc

J7322         Hymovis

J7332         Triluron

 

  • Will require documentation of trial and failure of Remicade, Inflectra, and Avsola (PA already exists):

Q5104       Renflexis

 

  • Will require documentation of trial and failure of Neulasta and Udenyca (PA already exists):

Q5122       Byvepria

Q5108       Fulphila 

Q5120       Ziextenzo

 

  • Will require documentation of trial and failure of Sandostatin LAR (PA already exists):

J1930         Somatuline Depot