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CMS allows Medicare Advantage plans to implement Step Therapy requirements for the Medicare Part B drugs. Mercy Care Advantage members will be required to utilize the preferred Part B drugs included in the CVS Caremark® Advanced Biosimilars-First Medical Preferred Drug List. This new Part B Drug Step Therapy list is effective January 1, 2023, and is available for your review on the MCA website.
Mercy Care Advantage members must use the preferred Part B drug products first. An exception process is in place for specific circumstances that may warrant a need for a non-preferred Part B drug product. In this situation, providers can submit a supporting statement reflecting trial and failure of the non-preferred drug(s), or medical reason why the member cannot take non-preferred drug(s), or medical reason why the non-preferred drug(s) would not be as effective as the preferred drug for the member.
The step therapy requirement does not apply to Mercy Care Advantage members who are actively receiving treatment (i.e., members with a paid claim within the past 365 days) with non-preferred product on the CVS Caremark Advanced Biosimilars-first Medical Preferred Drug List.
Providers may submit requests for prior authorization and/or a step therapy exception for Medicare Part B drugs when medically necessary.
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Standard requests for can be faxed to the Prior Authorization department at 800-217-9345. Our prior authorization form can be found on Mercy Care website under the Provider Forms tab and selecting Prior Authorization Standard Request Form.
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For urgent requests, please call 602-623-3000 or 800-624-3879.
In the meantime, don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care Advantage website.
Thanks for all you do!
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