Part B Step Therapy Criteria for Approval
Riabni, Rituxan, and Rituxan Hycela will be approved when ALL of the following are met:
- The requested medication is being used for ONE of the following:
- An FDA approved indication
OR - An indication in CMS approved compendia
AND
- An FDA approved indication
- ONE of the following:
- Information has been provided that indicates the patient has been treated with the requested medication in the past 365 days
OR - There is documentation that the patient has had an ineffective treatment response to the active ingredient(s) of ALL preferred medication(s)
OR - The patient has a documented intolerance, hypersensitivity, or FDA labeled contraindication to the active ingredient(s) of ALL preferred medication(s)
OR - The prescriber has submitted documentation indicating ALL preferred medication(s) are likely to be ineffective or are likely to cause an adverse reaction or other harm to the patient
OR - BOTH of the following (for oncology indications):
- The National Comprehensive Cancer Network (NCCN) does NOT specify the preferred medication(s) as a preferred regimen for the requested indication
AND - NCCN specifies the requested medication as a preferred regimen for the requested indication
- The National Comprehensive Cancer Network (NCCN) does NOT specify the preferred medication(s) as a preferred regimen for the requested indication
- Information has been provided that indicates the patient has been treated with the requested medication in the past 365 days
Length of approval: 12 months
See table of preferred medications below
NOTES:
- Rituxan Hycela is NOT indicated for non-oncologic diagnoses
- Prerequisite medications may require prior review under Medicare Part D or Medicare Part B. Medicare Part D prerequisites will not be required for Medical Only members.
- Length of approval may be shorter due to provider network participation status.
- Coverage of one Medicare Part B Step Therapy medication could equate to multiple medication authorizations when they share the same Medicare Part B Step Therapy criteria.
- LCD/NCD criteria review completed, if applicable, in addition to the Plan’s Medicare Part B Step Therapy criteria.
| Targeted Part B Medication | Preferred Medications*† |
|---|---|
| Riabni (rituximab-arrx) | Ruxience (rituximab-pvvr) and Truxima (rituximab-abbs) |
| Rituxan (rituximab) | Ruxience (rituximab-pvvr) and Truxima (rituximab-abbs) |
| Rituxan Hycela (rituximab and hyaluronidase human) | Ruxience (rituximab-pvvr) and Truxima (rituximab-abbs) |
*Preferred medications may vary based upon indication
†Preferred medications require prior authorization under the member’s medical (Part B) benefit
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