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In August 2018, CMS rescinded its September 2012 memo “Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services,” which provided Medicare Advantage plans the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 Name – Status – Billing Code:
pamidronate Preferred J2430
zoledronic acid Preferred J3489
Xgeva Nonpreferred J0897
Drug Class: Colony Stimulating Factors –Leukocyte Growth Factors (long-acting)
Drug Name – Status – Billing 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 Name – Status – Billing Code:
Neupogen Preferred J1442
Nivestym Preferred Q5110
Granix Nonpreferred J1447
Zarxio Nonpreferred Q5101
Drug Class: COPD
Drug Name – Status – Billing Code(s):
Perforomist Preferred J7606
Brovana Nonpreferred J7605
Drug Class: Doxorubicin (liposomal)
Drug Name – Status – Billing Code(s):
doxorubicin conventional Preferred J9000
epirubicin Preferred J9178
Doxil Nonpreferred Q2050
Drug Class: Erythropoiesis-stimulating agents
Drug Name – Status – Billing Code(s):
Retacrit Preferred Q5106
Aranesp Nonpreferred J0881
Epogen Nonpreferred J0885
Mircera Nonpreferred J0888
Procrit Nonpreferred J0885
Drug Class: Gaucher’s disease
Drug Name – Status – Billing Code(s):
Cerdelga Preferred J8499
Cerezyme Preferred J1786
Elelyso Preferred J3060
Vpriv Nonpreferred J3385
Zavesca Nonpreferred J8499
Drug Class: Hemophilia A
Drug Name – Status – Billing 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 Name – Status – Billing Code(s):
Ruconest Preferred J0596
Berinert Nonpreferred J0597
Firazyr Nonpreferred J1744
icatibant Nonpreferred J1744
Kalbitor Nonpreferred J1290
Drug Class: Hereditary angioedema – prophylaxis
Drug Name – Status – Billing Code(s):
Haegarda Preferred J0599
Cinryze Nonpreferred J0598
Takhzyro Nonpreferred J0593
Drug Class: Immunologic drugs – autoimmune disorders (arthritis, psoriasis, inflammatory bowel disease
Drug Name – Status – Billing 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 Name – Status – Billing Code(s):
azacitidine Preferred J9025
Dacogen Nonpreferred J0894
decitabine Nonpreferred J0894
Drug Class: Neoplasms (excluding pancreatic)
Drug Name – Status – Billing Code(s):
docetaxel Preferred J9171
paclitaxel Preferred J9267
Abraxane Nonpreferred J9264
Drug Class: Ophthalmic disorders
Drug Name – Status – Billing 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 Name – Status – Billing Code(s):
zoledronic acid Preferred J3489
Prolia Nonpreferred J0897
Drug Class: Rituximab and hyaluronidase
Drug Name – Status – Billing Code(s):
Rituxan IV Preferred J9312
Rituxan Hycela Nonpreferred J9311
Drug Class: Somatostatin analogs (Lutathera)
Drug Name – Status – Billing Code(s):
Sandostatin LAR Preferred J2353
Somatuline Depot Preferred J1930
Lutathera Nonpreferred A9513
Drug Class: Somatostatin analogs (Signifor LAR)
Drug Name – Status – Billing Code(s):
octreotide acetate Preferred J2354
Sandostatin Preferred J2354
Signifor LAR Nonpreferred J2502
Drug Class: Trastuzumab and hyaluronidase‐oysk
Drug Name – Status – Billing 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 Name – Status – Billing Code(s):
vincristine sulfate Preferred J9370
Marqibo Nonpreferred J9371
Drug Class: Viscosupplements
Drug Name – Status – Billing 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;
