What's step therapy and how does it work?

Just because something’s expensive doesn’t mean it’s the best. If you’re a smart shopper, you find an option that costs less and works just as well.

That’s the idea behind step therapy. We use it to make sure you’re getting the most effective and reasonably-priced drug available.

Your pharmacists or doctor may tell you that some medications may need step therapy. They will review your medical information to find the best and lowest cost medication that can treat your problem.

Step therapy is trying lower-priced medications before taking a step up to one that costs more. Before trying an expensive drug, we’ll check to see if you’ve tried lower-priced drug options.

If you don’t follow the procedure for step therapy when it’s required, the drug may cost you more, or may not be covered at all.

Part B Step Therapy Drugs

These are the drugs the are Part B, meaning they are paid under your medical benefits

Drug Classes Drug Name Status Billing Code
Ophtalmic Disorders Avastin Preferred C9257, J9035
Eylea Non-Preferred J0178
Lucentis Non-Preferred J2778
Macugen Non-Preferred J2503
Visudyne Non-Preferred J3396
Viscosupplements Monovisc Preferred J7327
Orthovisc Non-Preferred J7324
Durolane Non-Preferred J7318
Euflexxa Non-Preferred J7323
Gel-One Non-Preferred J7326
Gelsyn-3 Non-Preferred J7328
Genvisc 850 Non-Preferred J7320
Hylagan Non-Preferred J7321
Hymovis Non-Preferred J7322
Supartz Non-Preferred J7321
Supartz FX Non-Preferred J7321
Synvisc Non-Preferred J7325
Synvisc-One Non-Preferred J7325
TriVisc Non-Preferred J7329
Visco-3 Non-Preferred J7321

For providers: A trial and failure of the preferred drug must be documented before a non-preferred drug will be approved. All non-preferred drugs must be prior authorized. The preferred drugs do not require prior authorization.