Medicare Part B Step Therapy, Effective January 1, 2024
Date: 11/22/23
Step Therapy programs are developed by Wellcare By Allwell's P&T Committee. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.
Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.
The first-line drugs on Wellcare By Allwell's formulary have been evaluated through the use of clinical literature and are approved by Wellcare By Allwell's P&T Committee. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on this list.
Drugs requiring step therapy effective January 1, 2024 are listed below. The prescriber, patient, or authorized representative may ask for an exception. Step therapy applies if the drug has not been used in the past 365 days.
Drug Name |
Abatacept (Orencia®) |
Ado-trastuzumab emtansine (Kadcyla®) |
Aflibercept (Eylea®) |
Atezolizumab (Tecentriq®) |
Axicabtagene ciloleucel (Yescarta®) |
Bevacizumab (Avastin®, Alymsys®, Mvasi®, Vegzelma™, Zirabev™) |
Brentuximab vedotin (Adcetris®) |
Brexucabtagene autoleucel (Tecartus™) |
Brolucizumab-dbll (Beovu®) |
Cemiplimab-rwlc (Libtayo®) |
Certolizumab (Cimzia®) |
Ciltacabtagene autoleucel (Carvykti™) |
Corticosteroid intravitreal implants: dexamethasone (Ozurdex®), fluocinolone acetonide (Iluvien®, Retisert®, Yutiq™) |
Corticotropin (H.P. Acthar®, Purified Cortrophin™ Gel) |
Daratumumab (Darzalex®), daratumumab/hyaluronidase-fihj (Darzalex Faspro™) |
Darbepoetin alfa (Aranesp®) |
Denosumab (Xgeva®) |
Durvalumab (Imfinzi®) |
Eflapegrastim-xnst (Rolvedon™) |
Elotuzumab (Empliciti®) |
Emapalumab-lzsg (Gamifant™) |
Epoetin alfa (Epogen®, Procrit®) |
Faricimab-svoa (Vabysmo™) |
Ferric carboxymaltose (Injectafer®) |
Ferric derisomaltose (Monoferric®) |
Ferric pyrophosphate (Triferic®, Triferic Avnu®) |
Ferumoxytol (Feraheme®) |
Filgrastim (Neupogen®, Zarxio®, Nivestym™, Granix®, Releuko®) |
Golimumab (Simponi®, Simponi Aria®) |
Hyaluronate derivatives: sodium hyaluronate (Euflexxa®, Gelsyn-3™, GenVisc®850, Hyalgan®, Supartz FX™, Synojoynt™, Triluron™, TriVisc™, VISCO-3™), hyaluronic acid (Durolane®), cross-linked hyaluronate (Gel-One®), hyaluronan (Hymovis®, Orthovisc®, Monovisc®), hylan polymers A and B (Synvisc®, Synvisc One®) |
Idecabtagene vicleucel (Abecma™) |
Immune globulins (Asceniv™, Bivigamâ, Cutaquigâ, Cuvitru™, Flebogammaâ DIF, GamaSTANâ, GamaSTANâ S/D, Gammagardâ liquid, Gammagardâ S/D, Gammaked™, Gammaplexâ, Gamunexâ-C, Hizentra®, HyQviaâ, Octagamâ, Panzygaâ, Privigenâ, Xembifyâ) |
IncobotulinumtoxinA (Xeomin®) |
Lisocabtagene maraleucel (Breyanzi®) |
Lurbinectedin (Zepzelca™) |
Luspatercept-aamt (Reblozyl®) |
Lutetium Lu 177 dotatate (Lutathera®) |
Nadofaragene firadenovec-vncg (Adstiladrin®) |
Natalizumab (Tysabri®) |
Nivolumab (Opdivo®) |
Pegfilgrastim (Neulasta®, Fulphila™, Fylnetra®, Nyvepria™, Stimufend®, Udenyca™, Ziextenzo™) |
Pembrolizumab (Keytruda®) |
Polatuzumab vedotin-piiq (Polivy™) |
Ramucirumab (Cyramza®) |
Ranibizumab (Lucentis®, Byooviz®, Cimerli™, Susvimo™) |
RimabotulinumtoxinB (Myobloc®) |
Rituximab (Rituxan®, Riabni™, Ruxience™, Truxima®), rituximab/hyaluronidase (Rituxan Hycela™) |
Romiplostim (Nplate®) |
Romosuzumab-aqqg (Evenity™) |
Sargramostim (Leukine®) |
Sipuleucel-T (Provenge®) |
Teclistamab-cqyv (Tecvayli®) |
Teprotumumab-trbw (Tepezza™) |
Tisagenlecleucel (Kymriah®) |
Tocilizumab (Actemra®) |
Trastuzumab (Herceptin®, Ontruzant®, Herzuma®, Ogivri™, Trazimera™, Kanjinti™), trastuzumab/hyaluronidase (Herceptin Hylecta™) |
Triamcinolone ER injection (Zilretta®) |
Triamcinolone acetonide suprachoroidal injection (Xipere™) |
Vedolizumab (Entyvio®) |
| Verteporfin (Visudyne®) |
Download a printable copy of the drugs requiring step therapy (PDF).
If you have any questions, please contact Medicare Pharmacy Services at 1-800-867-6564.
Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the policies listed above or any our Clinical & Payment Policies, please contact your Provider Relations representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who your representative is, please email us at WI_Provider_Relations@mhswi.com.