2021 Medicare Part B Step Therapy

What is Medicare Part B Step Therapy?

■ Starting in 2021, some medically administered Part B drugs, like injectables or biologics, may have special requirements or coverage limits, such as step therapy.

■ Step therapy requires a trial of a preferred drug to treat a medical condition before covering a non-preferred drug. 
   o Here’s an example: Drug A (preferred) and Drug B (non-preferred) are both used to treat the same medical condition.  We may require that you try Drug A (preferred) first. If Drug A does not work, we’ll then cover Drug B (non-preferred).

■ The step therapy requirement does not apply to members who have already received treatment with the non-preferred drug within the past 365 days.

■ Both preferred and non-preferred drugs may still be subject to prior authorization or quantity limits.

Click Here to Download the Medicare Part B Step Therapy Drug List.

Gateway Health offers HMO plans with a Medicare Contract. Some Gateway Health plans have a contract with Medicaid in the states where they are offered. Enrollment in these plans depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium – The State pays the Part B premium for full dual members. Please contact the plan for further details. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

• Medicare Ombudsman Website           
• Best Available Evidence