Part B Drug Step Therapy
Medicare Part B drugs are covered under Part B of Original Medicare. Members of our plan can access coverage for these drugs when medically necessary. For additional information, please see Chapter 4, Benefits Chart in the 2021 Mercy Care Advantage Evidence of Coverage.
CMS allows Medicare Advantage plans to implement Step Therapy requirements for the Part B drugs. Starting January 1, 2021, Mercy Care Advantage (MCA) members will be required to utilize the preferred Part B drugs listed on the CVS Caremark® Medical Preferred Drug List.
View the MCA Part B drug Step Therapy list
Providers may submit for Part B drug Prior Authorization or for a Step Therapy Exception for a preferred Part B drug by providing a supporting statement reflecting trial and failure of the preferred drug(s), or medical reason why the member cannot take the preferred drug(s), or medical reason why the preferred drug(s) would not be as effective as the non-preferred drug requested for the member.
Requests for Part B drug Prior Authorization, or a Step Therapy Exception can be faxed to the Medical Prior Authorization department at 800-217-9345 for standard requests. Standard requests for Part B drugs are reviewed within 72 hours. For expedited requests for Part B drugs, please call us at 602-623-3000 or 800-624-3879. Expedited requests are reviewed within 24 hours.
Providers may use the MCA Part B Prior Authorization and Step Therapy Exception Request form to make a request. A copy of this form is available under the Mercy Care Advantage Provider Forms webpage. Part B drug exception requests must be submitted with a physician supporting statement for the review process to begin. If this information is missing, the exception request will be tolled for a short period of time to allow for receipt of the supporting statement; if not received timely, a decision will be rendered based on the information available.