Providers
Medicare Part B Drug Prior Authorization Policy
InterQual® Criteria for Prior Authorization
When Blue Medicare receives a request for authorization or prior authorization for a Part B medication, our utilization review pharmacists & Medical Directors use Change Healthcare’s InterQual® criteria to determine if the services are clinically indicated. If the criteria are met, the case is approved; if the criteria are not met, the case is reviewed by a physician. InterQual criteria are clinically based on best practice, clinical data and medical literature. They are updated continually and released annually. In addition to the Interqual criteria, certain medications may require a step therapy (use of preferred drugs) prior to coverage of requested medications. Please see below for additional information.
Drug List requiring Prior Authorization [pdf]
Medicare Part B Step Therapy Program
Effective Date: January 1, 2023
This Part B Step therapy drug policy is applicable to all Medicare Advantage Plans offered by Arkansas Blue Cross Blue Shield (H3554, H6518, H9699) except for H4213 (PFFS).
This policy supplements the InterQual® criteria for Medicare Pharmacy that applies to the Medicare Advantage Plans administered by Arkansas Blue Cross Blue Shield for the purpose of determining coverage under Medicare Part B medical benefits. This step therapy policy implements a prior authorization requirement for medical benefit injectables only, such as buy & bill.
The following products require Step Therapy in addition to the Interqual criteria:
Intravitreal Vascular Endothelial Growth Factor (VEGF) Inhibitors
| Preferred Drug | Non-Preferred Drugs | Non-Preferred Drugs Step Therapy Criteria |
|---|---|---|
| Compounded Avastin | Beovu, Byooviz, Eylea, Lucentis, Susvimo, Vabysmo | Beovu, Byooviz, Eylea, Lucentis, Susvimo, or Vabysmo may be covered after an adequate trial/failure (at least 3 doses resulting in minimal clinical response to compounded Avastin). |
Bisphosphonate Drug Therapy
| Preferred Drug | Non-Preferred Drugs | Non-Preferred Drugs Step Therapy Criteria |
|---|---|---|
| Oral bisphosphonates | Prolia, Reclast | Non-Preferred drugs may be covered after an adequate trial/failure or documented intolerance resulting in minimal clinical response to oral bisphosphonate therapy. |
2024 Part B Step Therapy Preferred Drug List
2024 Part B Step Therapy Preferred Drug List
References
- Medicare Advantage and Part D Drug Pricing [pdf]
- Modernizing Part D and Medicare Advantage to lower drug prices and reduce out-of-pocket expenses
- For CMS Memorandum titled Prior Authorization and Step Therapy for Part B Drugs in Medicare Advantage, dated August 7, 2018; see MA Step Therapy HPMS Memo [pdf]
- Avery RL, Pieramici DJ, Rabena MD, Castellarin AA, Nasir MA, Giust MJ. Intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration. Ophthalmology. 2006;113(3):363-372. doi: 10.1016/j.ophtha.2005.11.019.
- Age-Related Macular Degeneration Preferred Practice Pattern. American Academy of Ophthalmology. Sept. 2019.
- Bakri SJ, Thorne JE, Ho AC, et al. Safety and efficacy of anti-vascular endothelial growth factor therapies for neovascular age-related macular degeneration: a report by the American Academy of Ophthalmology. Ophthalmology. 2019;126(1):55-63. doi: 10.1016/j.ophtha.2018.07.028.