Medicare Part B drug prior authorization policy

InterQual® criteria for prior authorization 

When Arkansas Blue Medicare receives a request for authorization or prior authorization for a Part B medication, our utilization review pharmacists and medical directors use Change Healthcare’s InterQual® criteria to determine if the services are medically necessary. If medical necessity is met, the case is approved; if it is not met, the case is reviewed by a medical director. InterQual criteria is clinically based on best practice, clinical data, and medical literature. The InterQual medical criteria is 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. 

• Part B medication prior authorization request form
• Drug list requiring prior authorization

Medicare Part B step therapy program 

This Part B step therapy drug policy is applicable to all Arkansas Blue Medicare HMO plans (CMS contracts H6518 and H9699). It is not applicable to Arkansas Blue Medicare PFFS plans (CMS contract H4213). 

This policy supplements the InterQual criteria for Medicare pharmacy that applies to Arkansas Blue Medicare plans 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. 

Part B step therapy preferred drug list

2026 Part B step therapy preferred drug list

References 

1. Medicare Advantage and Part D drug pricing
2. Modernizing Part D and Medicare Advantage to lower drug prices and reduce out-of-pocket expenses 
3. 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
4. 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.
5. Age-Related Macular Degeneration Preferred Practice Pattern. American Academy of Ophthalmology. Sept. 2019.
6. 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.