Part B Step Therapy Drug List

Step Therapy is a CMS recognized utilization management tool that helps achieve the goal of lower drug prices while also maintaining access to covered services and drugs. Healthy Mississippi, Inc requires review of some Part B drugs for step therapy requirements, and they are listed below.

Step Therapy Category	Drug Name	Status	Billing Code
Aniemetics for Oncology	Aloxi (palonosetron)	Preferred	J2469
	Emend (fosaprepitant)	Preferred	J1453
	Granisetron	Preferred	J1626
	Ondansetron	Preferred	J2405
	Akynzeo	Nonpreferred
	Cinvanti	Nonpreferred
	Sustol	Nonpreferred	J1627
Bevacizumab	Myasi	Preferred	Q5107
	Zirabev	Preferred	Q5118
	Alymsys	Nonpreferred	Q5126
	Avastin	Nonpreferred	J9035
	Vegzelma	Nonpreferred	Q5129
Bone Density Agents - Oncology	Alendronate	Preferred
	Ibandronate	Preferred	J1740
	Pamidronate	Preferred	J2430
	Risedronate	Preferred
	Zoledronic Acid	Preferred	J3489
	Prolia	Nonpreferred	J0897
	Xgeva	Nonpreferred	J0897
Bone Density Agents - Osteoporosis	Alendronate	Preferred
	Ibandronate	Preferred	J1740
	Pamidronate	Preferred	J2430
	Risedronate	Preferred
	Zoledronic Acid	Preferred	J3489
	Evenity	Nonpreferred	J3111
	Prolia	Nonpreferred	J0897
Colony Stimulating Factors	Zarxio	Preferred	Q5101
	Neulasta	Preferred	J2506
	Udenyca	Preferred	Q5111
	Granix	Nonpreferred	J1447
	Neupogen	Nonpreferred	J1442
	Nivestym	Nonpreferred	Q5110
	Releuko	Nonpreferred	Q5125
	Fulphila	Nonpreferred	Q5108
	Fylnetra	Nonpreferred	Q5130
	Nyvepria	Nonpreferred	Q5122
	Rolvedon	Nonpreferred	J1449
	Stimufend	Nonpreferred	Q5127
	Ziextenzo	Nonpreferred	Q5120
Gemcitabine	Gemcitabine	Preferred	J9201
Gemcitabine	Infugem	Nonpreferred	J9198
Gonadotropin Releasing Hormone Analogs for Oncology	Leuprolide acetate 7.5mg	Preferred	J9217
Gonadotropin Releasing Hormone Analogs for Oncology	Leuprolide acetate 3.75mg	Nonpreferred	J1950
Gout Agency	Allopurinol	Preferred	J0206
	Febuxostat	Preferred
	Krystexxa	Nonpreferred	J2507
Hyaluronic Acid Polymers	Durolane	Preferred	J7318
	Gelsyn-3	Preferred	J7328
	Synvisc	Preferred	J7325
	Synvisc-One	Preferred	J7325
	Euflexxa	Nonpreferred	J7323
	Gel-One	Nonpreferred	J7326
	Genvisc 850	Nonpreferred	J7320
	Hyalgan	Nonpreferred	J7321
	Hymovis	Nonpreferred	J7322
	Monovisc	Nonpreferred	J7327
	Orthovisc	Nonpreferred	J7324
	Supartz	Nonpreferred	J7321
	Supartz Fx	Nonpreferred	J7321
	Synojoynt	Nonpreferred	J7331
	Triluron	Nonpreferred	J7332
	TriVisc	Nonpreferred	J7329
	Visco-3	Nonpreferred	J7321
Immune Globulins	Bivigam	Preferred	J1556
	Cuvitru	Preferred	J1555
	Flebogamma DIF	Preferred	J1572
	Gammagard Liquid	Preferred	J1569
	Gammagard S/D	Preferred	J1566
	Gammaked	Preferred	J1561
	Gammaplex	Preferred	J1557
	Gamunex-C	Preferred	J1561
	Hizentra	Preferred	J1559
	HyQvia	Preferred	J1575
	Octagam	Preferred	J1568
	Privigen	Preferred	J1459
	Xembify	Preferred	J1558
	Alyglo	Nonpreferred	J1552
	Asceniv	Nonpreferred	J1554
	Cutaquig	Nonpreferred	J1551
	Panzyga	Nonpreferred	J1576
Infliximab	Avsola	Preferred	Q5121
	Inflectra	Preferred	Q5103
	Renflexis	Preferred	Q5104
	Infliximab	Nonpreferred	J1745
	Remicade	Nonpreferred	J1745
	Zymfentra	Nonpreferred	J1745
Intravenous Iron Replacement Therapy	Feraheme (ferumoxytol)	Preferred	Q0138
	Ferrlecit (sodium ferric gluconate complex)	Preferred	J2916
	INFeD	Preferred	J1750
	Venofer	Preferred	J1756
	Injectafer	Nonpreferred	J1439
	Monoferric	Nonpreferred	J1437
VEGF Inhibitors - Age Related	Compounded Avastin	Preferred	J7999
	then Eylea	Preferred	J0178
	Beovu	Nonpreferred	J0179
	Byooviz	Nonpreferred	Q5124
	Cimerli	Nonpreferred	Q5128
	Eylea HD	Nonpreferred	J0177
	Lucentis	Nonpreferred	J2778
	Susvimo	Nonpreferred	J2779
	Vabysmo	Nonpreferred	J2777
VEGF Inhibitors	Eylea	Preferred	J0178
	Beovu	Nonpreferred	J0179
	Byooviz	Nonpreferred	Q5124
	Cimerli	Nonpreferred	Q5128
	Eylea HD	Nonpreferred	J0177
	Lucentis	Nonpreferred	J2778
	Susvimo	Nonpreferred	J2779
	Vabysmo	Nonpreferred	J2777
Leucovorin	Leucovorin	Preferred	J0640
	Fusilev	Nonpreferred	J0641
	Khapzory	Nonpreferred	J0642
	Levoleucovorin	Nonpreferred	J0641
Lipid Modifying Agents	Praluent	Preferred	J3490/J3590
	Repatha	Preferred	J3490/J3590
	Leqvio	Nonpreferred	J1306
Migraine Prophylaxis	Aimovig	Preferred	J3590
	Ajovy	Preferred	J3031
	Emgality	Preferred	J3590
	Vyepti	Nonpreferred	J3032
Rituximab	Ruxience	Preferred	Q5119
	Truxima	Preferred	Q5115
	Riabni	Nonpreferred	Q5123
	Rituxan	Nonpreferred	J9312
	Rituxan Hycela	Nonpreferred	J9311
Systemic Lupus Erythematosus Agents	Benlysta	Preferred	J0490
Systemic Lupus Erythematosus Agents	Saphnelo	Nonpreferred	J0491
Trastuzumab	Kanjinti	Preferred	Q5117
	Ogivri	Preferred	Q5114
	Trazimera	Preferred	Q5116
	Herceptin	Nonpreferred	J9355
	Herceptin Hylecta	Nonpreferred	J9356
	Herzuma	Nonpreferred	Q5113
	Ontrazant	Nonpreferred	Q5112

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We remain committed to helping you access the right care at the right time. If you have questions about this update or how it may affect your coverage, please don’t hesitate to contact our team at 1-833-201-6413 TTY:711 or healthymsplan@healthy-ms.com. Our hours of availability are 8 AM – 8 PM CST, 7 days a week from October 1 to March 31, and Monday through Friday from April 1 to September 30.

Part B Step Therapy Drug List

Part B Step Therapy Drug List

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