Humana Updates Requirements for Injectable Drugs and Biologics Step Therapy for Medicare Advantage Plans

December 2019 ~

Effective January 1, 2020, Humana will no longer offer a Drug Management Care Coordination Program (DM-CCP) for patients subject to step therapy and/or taking a preferred drug on the Part B Step Therapy Drug List.

According to the insurer, per CMS guidance, in 2020, health plans will not be required to couple step therapy with a rewards and incentives program. Instead, MA plans must incorporate anticipated savings from implementing Part B step therapy into their bid amounts for each plan, which, in turn, may be used to provide supplemental benefits and/or lower premiums to the plans’ enrollees.

In August 2018, CMS rescinded its September 2012 memo “Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services,” which provided Medicare Advantage plans the option of applying step therapy for physician-administered and other Part B drugs. Due to this change, Humana added step therapy requirements in 2019 for some drugs on our preauthorization list.

CMS later issued a final ruling on May 16, 2019, that modernizes and improves the Medicare Advantage program.2 These changes finalized CMS requirements for the Part B Step Therapy program, enabling Medicare Advantage plans to negotiate better prices for physician-administered medicines in Part C. The changes as a result of this final ruling will be implemented January 1, 2020.

Humana notes that the step therapy requirement will not apply to patients who already are actively receiving treatment with a nonpreferred drug (have a paid drug claim within the past 365 days). Medicare Advantage patients subject to the step therapy requirement may:

  • Request expedited exception reviews for step therapy prior authorization requests.
  • Appeal a denied request for a nonpreferred drug due to step therapy requirements.

Drug Class: Bone resorption inhibitors

Drug NameStatusBilling Code:

pamidronate Preferred J2430

zoledronic acid Preferred J3489

Xgeva Nonpreferred J0897

Drug Class: Colony Stimulating Factors –Leukocyte Growth Factors (long-acting)

Drug NameStatusBilling Code:

Fulphila Preferred Q5108

Neulasta / Neulasta

Onpro Preferred J2505

Udenyca Preferred Q5111

Ziextenzo Nonpreferred C9399, J9999 

Drug Class: Colony-stimulating factors – leukocyte growth factors (short-acting)

Drug NameStatusBilling Code:

Neupogen Preferred J1442

Nivestym Preferred Q5110

Granix Nonpreferred J1447

Zarxio Nonpreferred Q5101

Drug Class: COPD

Drug NameStatusBilling Code(s):

Perforomist Preferred J7606

Brovana Nonpreferred J7605

Drug Class: Doxorubicin (liposomal)

Drug NameStatusBilling Code(s):

doxorubicin conventional Preferred J9000

epirubicin Preferred J9178

Doxil Nonpreferred Q2050

Drug Class: Erythropoiesis-stimulating agents

Drug NameStatusBilling Code(s):

Retacrit Preferred Q5106

Aranesp Nonpreferred J0881

Epogen Nonpreferred J0885

Mircera Nonpreferred J0888

Procrit Nonpreferred J0885

Drug Class: Gaucher’s disease

Drug NameStatusBilling Code(s):

Cerdelga Preferred J8499

Cerezyme Preferred J1786

Elelyso Preferred J3060

Vpriv Nonpreferred J3385

Zavesca Nonpreferred J8499

Drug Class: Hemophilia A

Drug NameStatusBilling Code(s):

Advate Preferred J7192

Adynovate Preferred J7207

Afstyla Preferred J7210

Eloctate Preferred J7205

Helixate FS Preferred J7192

Hemofil-M Preferred J7190

Jivi Preferred J7208

Koate-DVI Preferred J7190

Kogenate FS Preferred J7192

Kovaltry Preferred J7211

Monoclate-P Preferred J7190

NovoEight Preferred J7182

Nuwiq Preferred J7209

Recombinate Preferred J7192

Xyntha Preferred J7185

Hemlibra Nonpreferred J7170

Drug Class: Hereditary angioedema – acute use

Drug NameStatusBilling Code(s):

Ruconest Preferred J0596

Berinert Nonpreferred J0597

Firazyr Nonpreferred J1744

icatibant Nonpreferred J1744

Kalbitor Nonpreferred J1290

Drug Class: Hereditary angioedema – prophylaxis

Drug NameStatusBilling Code(s):

Haegarda Preferred J0599

Cinryze Nonpreferred J0598

Takhzyro Nonpreferred J0593

Drug Class: Immunologic drugs – autoimmune disorders (arthritis, psoriasis, inflammatory bowel disease

Drug NameStatusBilling Code(s):

Inflectra Preferred Q5103

Remicade Preferred J1745

Simponi Aria Preferred J1602

Stelara Preferred J3358

Actemra IV Nonpreferred J3262

Entyvio Nonpreferred J3380

Ilumya Nonpreferred J3245

Orencia IV Nonpreferred J0129

Renflexis Nonpreferred Q5104

Rituxan IV Nonpreferred J9312

Tysabri Nonpreferred J2323

Drug Class: Myelodysplastic syndrome

Drug NameStatusBilling Code(s):

azacitidine Preferred J9025

Dacogen Nonpreferred J0894

decitabine Nonpreferred J0894

Drug Class: Neoplasms (excluding pancreatic)

Drug NameStatusBilling Code(s):

docetaxel Preferred J9171

paclitaxel Preferred J9267

Abraxane Nonpreferred J9264

Drug Class: Ophthalmic disorders

Drug NameStatusBilling Code(s):

Avastin Preferred C9257, J9035

Beovu Nonpreferred C9399, J3490, J3590

Eylea Nonpreferred J0178

Lucentis Nonpreferred J2778

Macugen Nonpreferred J2503

Visudyne Nonpreferred J3396

Drug Class: Osteoporosis

Drug NameStatusBilling Code(s):

zoledronic acid Preferred J3489

Prolia Nonpreferred J0897

Drug Class: Rituximab and hyaluronidase

Drug NameStatusBilling Code(s):

Rituxan IV Preferred J9312

Rituxan Hycela Nonpreferred J9311

Drug Class: Somatostatin analogs (Lutathera)

Drug NameStatusBilling Code(s):

Sandostatin LAR Preferred J2353

Somatuline Depot Preferred J1930

Lutathera Nonpreferred A9513

Drug Class: Somatostatin analogs (Signifor LAR)

Drug NameStatusBilling Code(s):

octreotide acetate Preferred J2354

Sandostatin Preferred J2354

Signifor LAR Nonpreferred J2502

Drug Class: Trastuzumab and hyaluronidase‐oysk

Drug NameStatusBilling Code(s):

Herceptin (IV) Preferred J9355

Herzuma Preferred Q5113

Kanjinti Preferred Q5117

Ogivri Preferred Q5114

Ontruzant Preferred Q5112

Trazimera Preferred Q5116

Herceptin Hylecta Nonpreferred J9356

Drug Class: Vincristine (liposomal)

Drug NameStatusBilling Code(s):

vincristine sulfate Preferred J9370

Marqibo Nonpreferred J9371

Drug Class: Viscosupplements

Drug NameStatusBilling Code(s):

Monovisc Preferred J7327

Orthovisc Preferred J7324

Durolane Nonpreferred J7318

Euflexxa Nonpreferred J7323

Gel-One Nonpreferred J7326

Gelsyn-3 Nonpreferred J7328

GenVisc 850 Nonpreferred J7320

Hyalgan Nonpreferred J7321

Hymovis Nonpreferred J7322

Sodium Hyaluronate Nonpreferred C9399, J3490

Supartz FX Nonpreferred J7321

Synvisc Nonpreferred J7325

Synvisc One Nonpreferred J7325

Triluron Nonpreferred J7332

TriVisc Nonpreferred J7329

Visco-3 Nonpreferred J7321

A complete list of affected drugs can be viewed on Humana’s Medicare preauthorization list.

Source(s): Humana’s YourPractice;