Medical Drug Step Therapy Changes

Effective for dates of service beginning Jan. 1, 2023, CarePartners of Connecticut is updating our step therapy requirements for medical benefit drugs.

Step therapy requires that members first try certain preferred drugs to treat their medical condition before coverage of another non-preferred drug for that condition is approved as medically necessary. Non-preferred products must meet the following criteria: history of use of at least one preferred product resulting in substandard response, history of intolerance or adverse event of at least one preferred product or have rationale that the preferred products are not clinically appropriate.

For complete information, please refer to the Medicare Part B Step Therapy Medical Necessity Guideline. Some of the changes include:

• Cerezyme (J1786) will be a non-preferred product and will require prior authorization. Preferred products in this class, which do not require prior authorization are: Eleyso (J3060) or Vpriv (J3385).
• Riabni (Q5123) will now be a non-preferred product in the rituximab class — along with existing non-preferred medical drugs Rituxan (J9312) and Rituxan Hycela (J9311) — and will require prior authorization. Preferred products are Ruxience (Q5119) or Truxima (Q5115).
• Herzuma (Q5113) and Ontuzant (Q5112) will now be non-preferred products in the trastuzumab class — along with existing non-preferred medical drugs Herceptin (J9355) and Herceptin Hylecta (J9356) —and will require prior authorization. Preferred products Kanjinti (Q5117), Ogivri (Q5114), and Trazimera (Q5116) will not require prior authorization.

For more information, also refer to the applicable Medical Benefit Drug Medical Necessity Guideline.