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Part B drug step therapy
The Centers for Medicare & Medicaid Services (CMS) lets Medicare Advantage plans implement step therapy requirements for Part B drugs. We have done so and use the 2024 CVS Caremark® Advanced Biosimilars - First Medical Preferred Drug List - Medicare Part B Step Therapy (PDF) or 2025 Advanced Biosimilars-first Medical Preferred Drug List.
You can submit PA for:
Medicare Part B drugs that are medically necessary
Non-preferred Medicare Part B drugs instead of preferred Part B drugs: usually applies when people are already in an active course of treatment
Just provide one of these:
A supporting statement reflecting trial and failure of the preferred drug
A medical reason the member can’t take the preferred drug
A medical reason the preferred drug wouldn’t be as effective as the requested non-preferred drug
How to submit PA
Fax our Medical Prior Authorization Department at 1-800-217-9345. We’ll review:
Standard requests within 72 hours
Expedited requests within 24 hours
Glucose meters and supplies
FreeStyle Libre® and Dexcom® are the preferred brands of continuous glucose meters and supplies.
OneTouch® is the preferred brand of glucose meters and test strips.
Non-preferred diabetes supplies need PA.
Learn more about Part B
Read about Part B drugs in Chapter 4, Benefits Chart in the Mercy Care Advantage Evidence of Coverage 2024 EOC, 2025 EOC - ACC DD or 2025 EOC - ALTCS.
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