Part B Drug Step Therapy
Medicare Part B drugs are covered under Part B of Original Medicare. MCA members can access coverage for these drugs when medically necessary. For additional coverage information about Part B drugs, please reference the Mercy Care Advantage Evidence of Coverage, Chapter 4, Benefits Chart.
CMS allows Medicare Advantage plans to implement Step Therapy requirements for the Part B drugs. Mercy Care Advantage has implemented Step Therapy for Part B drugs and utilizes the CVS Caremark® Medical Preferred Part B Step Therapy drug list.
View the 2023 MCA Part B Drug Step Therapy List
Providers may submit for prior authorization for Medicare Part B drugs when medically necessary. Providers may also request prior authorization for a member to use a non-preferred Part B drug instead of the Preferred Part B Step Therapy drug. This typically applies when a member is already in an active course of treatment. In this situation it is important for the provider to include 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 can be faxed to our Prior Authorization department at 800-217-9345. Prior authorization requests for Part B drugs will be reviewed and processed within 24 hours for an expedited request and 72 hours for a standard request.