Grand Junction and Mesa County · Infusions and injections in 2027

Does Medicare Advantage Use Step Therapy in Grand Junction?

Yes. All 13 general Advantage plans in Mesa County tell CMS they can use step therapy for 2027 on drugs given in a doctor's office or infusion center. That covers eye injections, bone-density shots and infusions. Original Medicare doesn't use step therapy at all.

Medicare On Main Data Desk

Published November 9, 2026 · 7 min read · Reviewed by Brian Penner, 22+ years in Medicare

The standard answer: what step therapy is and who uses it

Part B covers drugs you don't pick up at a pharmacy. Medicare.gov says it covers "most injectable and infused drugs when a licensed medical provider gives them," along with osteoporosis injections, some cancer drugs, immune globulin and others. Under Original Medicare there's no preferred-drug list for these. If the drug is medically necessary and approved for your condition, Part B pays its share.

Medicare Advantage plans can add a step. In 2018 CMS announced that, starting in 2019, Advantage plans could use step therapy for Part B drugs. The plan names a preferred drug for a condition, and you try that one before it pays for another. The rule is 42 CFR § 422.136, which sets the limits covered below.

Nationally it's optional, and plans differ. In Mesa County for 2027, every general plan uses it.

Which Mesa County plans use step therapy for 2027

Each plan reports its Part B drug rules in CMS's 2027 plan benefit file. All 13 general plans answer yes to step therapy. They differ on which kind of step they file:

• Part B to Part B: try one office-given drug before another. All 13 plans.
• Part D first: try a pharmacy drug before the plan pays for an office-given one. Four plans.
• Part B first: try an office-given drug before the plan pays for a pharmacy drug. Seven plans.

Sources: CMS 2027 benefit file, section 15 (Medicare Part B drugs), step-therapy type field; premiums and maximums from the CMS CY2027 landscape. "—" means the plan didn't file that kind of step. You still pay your Part B premium. Listing a plan is reporting, not a recommendation, and we do not offer every plan available in your area.

The filing tells you a plan can use step therapy. It doesn't tell you which drugs are affected. Each carrier publishes its own list, and that's the document to check.

What a step therapy list actually looks like

Humana publishes its list, and its 2027 version takes effect January 1, 2027. It shows the kind of drugs involved. I'm using it as an example, not because it's stricter or looser than the others:

• Eye injections for macular degeneration: Avastin, Byooviz, Eylea, Eylea HD, Lucentis, Pavblu and Vabysmo are preferred. Beovu, Cimerli and Susvimo are among the nonpreferred.
• Osteoporosis shots: Prolia is preferred, and Evenity is among the nonpreferred.
• Knee osteoarthritis injections: plain steroid injections are preferred over Zilretta.
• Plus infusions for rheumatoid arthritis and Crohn's disease, cancer support drugs, IV iron, immune globulin and other groups.

Most people never hit a step, because their doctor's usual choice is already preferred. It matters when your specialist wants a nonpreferred drug for a reason, such as a better response or fewer injections. The other carriers in Mesa County set their own preferred drugs, so the same injection can be preferred on one plan and a step on another.

The rules that protect you

The regulation limits how far a plan can go:

• Only new starts. A plan can "apply step therapy only to new administrations of Part B drugs, using at least a 365 day lookback period." If you've had the drug in the past year, the step shouldn't apply. Humana's 2027 list says the same: the requirement "will not apply to patients who are already actively receiving treatment" with a paid claim in the past year.
• A clinical committee signs off. A pharmacy and therapeutics committee, mostly practicing physicians and pharmacists, must approve each program.
• Covered drugs only. A plan can't make you try a drug it doesn't cover.
• Fast decisions. When your doctor asks for a Part B drug, the plan has to answer within 72 hours, and within 24 hours if the request is expedited. A denial comes in writing with your appeal rights.

Switching carriers is the risky case. Your new plan may not see claims your old plan paid. If you change plans for January, have your specialist's office send the new plan your treatment history before your next appointment. Our prior authorization post covers the 90-day transition rule that also applies.

What Part B drugs cost on these plans

All 13 plans file 0% to 20% coinsurance for Part B drugs in 2027, including chemotherapy drugs, with no separate drug deductible. All 13 can also require prior authorization. Insulin used in a Part B pump is capped at $35 a month (Medicare.gov).

The cap is what makes 20% manageable. These drugs can be expensive, and on an Advantage plan your coinsurance counts toward the in-network maximum, $4,900 to $9,850 on the Mesa County plans. Someone on monthly eye injections or a regular infusion can reach that maximum, and a lower cap is worth more to them than a $0 premium. Our 2027 out-of-pocket maximum post compares the caps.

The Original Medicare and Medigap comparison

On Original Medicare, an eye injection costs you 20% of the Medicare-approved amount for the drug and the doctor's service after the Part B deductible. In a hospital outpatient setting you also pay a facility copayment. There's no step therapy and no network, so any Grand Junction specialist who takes Medicare can give you the drug your doctor picks. There's also no yearly cap.

Medigap fills that gap. With Plan G you pay the Part B deductible once a year, and the plan covers the 20% after that. For someone already on an expensive office-given drug, that combination means no step therapy, no prior authorization from a plan, and a predictable yearly cost. The trade-off is the Medigap premium and, after your first Medigap window, Colorado underwriting. Our Plan G vs. Plan N post covers those rules.

Before you pick a 2027 plan

• Write down every drug you get at a doctor's office or infusion center, not just your pharmacy prescriptions. Plan finders mostly check Part D.
• Find each one on the carrier's Part B step therapy list and note whether it's preferred.
• Ask your specialist's office which plans give them the most step therapy and approval trouble. They deal with it every week.
• Check your pharmacy drugs separately. Our Part D drug check post walks through that.

Open Enrollment runs through December 7, and changes take effect January 1.

How we know all this: the Medicare On Main Data Desk frames every article with public data. Here that means CMS's 2027 plan benefit and landscape files, 42 CFR §§ 422.136, 422.568 and 422.572 as published by Cornell's Legal Information Institute, CMS's 2018 fact sheet, Medicare.gov's Part B drug, macular degeneration and insulin pages, and Humana's published 2027 Part B step therapy list, all read November 9, 2026. Benefits and drug lists can change, so confirm them in a plan's Evidence of Coverage and current list. Carrier names are factual reporting, not endorsement. This is education, not advice. Talk with your doctor about treatment, and compare plans with a licensed agent or Medicare.gov. We take no payment from any carrier to feature a plan.