Medicare AdvantagePrior AuthMedium impact
Update to Step Therapy Medical Benefit Drug Coverage for Medical Mutual Medicare Advantage Plans
Medical Mutual of Ohio·Oncology, Ophthalmology·Pharmacy
Effective date
Jan 1, 2023
We identified it
Jun 20, 2026
Summary
Medical Mutual Medicare Advantage plans updated their step therapy requirements effective Jan 1, 2023. New patients requiring Susvimo (J2779) or Vabysmo (J3590, C9097) must first try Avastin (J9035), while the step therapy requirement for Doxil (Q2050) was removed - patients can now receive it without trying conventional doxorubicin first.
Action Required
By Jan 1, 2023: Billing team must update prior authorization protocols for Medical Mutual Medicare Advantage patients. For J2779 and J3590/C9097, verify patients have tried J9035 first or obtain prior auth for medical necessity. Remove step therapy requirements for Q2050 - no prior trial of J9000 needed. Update EMR alerts and prior auth checklists accordingly.