Medicare Part B preferred drug list — Aetna Medicare Advantage (MA) only plans
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Aetna's Medicare Advantage (MA) Part B preferred drug list describing preferred and non-preferred medically administered (Part B) drugs, applicable utilization management (e.g., step therapy, prior authorization) and HCPCS codes for providers and administrators.
No material clinical or coverage changes in this revision.
Coverage criteria and product-specific rules
inv-01: Bone resorption inhibitors - initial coverage logic
Preferred products and step therapy rules for bone resorption inhibitors
Specific product-level step therapy criteria and links provided per drug
inv-02: Alpha-1 proteinase inhibitors
Alpha-1 antitrypsin deficiency products
Indication subject to step therapy; linked criteria referenced
inv-03: Botulinum toxins
Botulinum toxin coverage notes
Specific product-level step therapy or criteria links provided per product
inv-04: Colony stimulating factors
Colony stimulating factors
See linked criteria for product-specific requirements
inv-05: Coverage notes for listed products
Coverage and step therapy statements for listed erythropoiesis-stimulating agents and selected specialty drugs
Some indications are explicitly 'subject to step therapy' (e.g., anemia due to zidovudine; transfusion reduction for select surgeries)
inv-06: Prior authorization / medical necessity distinctions
Prior authorization and medical necessity link indications
Document provides external links to medical necessity criteria and fax request forms for many products
inv-07: Step therapy / Prior authorization criteria (partial)
Covered when meeting product-specific prior authorization and step therapy criteria (links referenced in document).
Providers must follow the linked criteria and fax forms where indicated
inv-08: IV iron initial coverage
Intravenous iron is covered when the following conditions are met
Certain IV iron products (Feraheme Q0139/Q0138, Injectafer J1439, Monoferric J1437) are listed with step therapy/linked criteria while other IV iron products (Ferrlecit J2916, sodium ferric gluconate J2916, Infed J1750, Venofer J1756) are noted as 'Prior authorization is not required'
inv-09: Remicade and biosimilars
Remicade and biosimilars coverage grouping
Non-preferred infliximab products may be subject to step therapy; see product-level links
inv-10: Sample PA exceptions vs PA-required placeholders
Mixed coverage/authorization statements present in excerpt; individual drug entries reference either 'Prior authorization is not required' or 'Link to criteria' indicating PA required.
Providers should consult the individual product rows for the PA status and use the linked fax forms/criteria when required
inv-11: Rituximab and biosimilars - step therapy
Step therapy application example
Document explicitly lists the rheumatoid arthritis exception for rituximab
inv-12: Ophthalmic VEGF inhibitor tiering
Coverage and prior authorization notes for categories and products
Specific tiering and step therapy links are provided in the ophthalmic VEGF inhibitor entries
inv-13: Product-specific prior authorization
Prior authorization status varies by product
See the product-level 'Medical necessity criteria' and 'Fax request form' links for submission requirements
Non-preferred products are identified in the policy listings. Approval for non-preferred agents is contingent on meeting the referenced product-level medical necessity and step therapy criteria linked in each drug row (for example, bone resorption inhibitors include preferred-first language and links to criteria for second‑tier or non‑preferred agents). Providers should follow the linked criteria for the specific non‑preferred product when submitting requests.
The excerpt does not list plan-level exclusions for specific drugs within these chunks. For complete descriptions of benefits, exclusions, limitations, and conditions of coverage, refer to the plan's Evidence of Coverage as noted in the document.
Several product entries explicitly note that Prior authorization is not required for specific drugs in the excerpt. Examples include pamidronate and zoledronic acid in the bone resorption inhibitor category and multiple gonadotropin‑releasing hormone agonists (e.g., Lupron depot, Trelstar, Zoladex) which are shown with prior‑authorization not required language; other agents elsewhere (for example some chemotherapy drugs) are also marked as PA not required. Providers should verify the PA status on the individual product row and use the linked fax form/criteria when PA is required.
Within the intravenous iron category some products are listed as preferred with Prior authorization is not required (e.g., Ferrlecit, sodium ferric gluconate, Infed, Venofer). Other IV iron formulations (Feraheme, Injectafer, Monoferric) are shown under non‑preferred or labeled with step therapy language and reference links to step therapy/criteria—meaning they may be excluded from preferred coverage unless the step therapy criteria are met.
Requests for rituximab and its biosimilars are generally listed as subject to step therapy but the document explicitly exempts rheumatoid arthritis from that step therapy requirement: all requests except rheumatoid arthritis are subject to step therapy. This is an explicit exception to the step therapy requirement for that indication.
There are no explicit item‑level exclusions called out in these chunks. The document directs readers to the Evidence of Coverage for a complete description of plan exclusions, limitations, and conditions of coverage.
The excerpt does not contain explicit 'not medically necessary' determinations for specific drugs. Coverage decisions in this document are presented as conditional on meeting the product‑specific medical necessity and step therapy criteria referenced in each drug row.
No explicit statements labeling specific drugs as 'not medically necessary' are provided in this excerpt. Providers should consult the linked product medical necessity criteria and the plan Evidence of Coverage for any determinations about non‑coverage.
These chunks do not include explicit 'not medically necessary' language. The policy framework emphasizes that coverage is determined by meeting the listed medical necessity and step therapy criteria; plan exclusions and coverage limitations are referenced to the Evidence of Coverage.
HCPCS/J-code mapping and code tables
| J0256 | Prolastin-C, Zemaira (alpha-1 proteinase inhibitors) |
| J9217 | Referenced category/code placeholder repeated in excerpt |
| J3380 | Entyvio IV (listed mapping) |
| J1745 | Remicade |
| Q5103 | Inflectra (biosimilar) or listed Q-code in excerpt |
| Q9997 | Pyzchiva IV (Q9997 listed) |
| Q5121 | Avsola (Q5121) |
| Q5098 | Imuldosa IV (Q5098) |
| Q9999 | Otulfi IV (Q9999) |
| Q9998 | Selarsdi IV (Q9998) |
| J3590 | Starjemza IV (J3590) |
| C9257 | Bevacizumab (Avastin) - HCPCS C9257/J7999 listed |
| J7999 | Bevacizumab (Avastin) - miscellaneous code listed |
| J0178 | Eylea |
| J0177 | Eylea HD |
| Q5124 | Byooviz |
| Q5147 | Pavblu |
| Q5150 | Ahzantive |
| Q5149 | Enzeevu |
| J3590 | Eydenzelt (misc codes J3590/C9399) |
| C9399 | Eydenzelt (misc codes J3590/C9399) |
What providers must do (authorization, forms, step therapy)
Prior authorization requirements vary by product
Prior authorization requirements vary by product. Some drugs explicitly require prior authorization, others do not, and many infused specialty agents are mapped to HCPCS/J‑codes with individual prior‑authorization rules. Verify the specific product-level entry and linked medical necessity criteria before ordering.
- Prior authorization status differs by drug and indication — review the product row for Prior authorization notes (e.g., some entries show “Prior authorization” while others show “Prior authorization is not required”).
- Many infused specialty drugs are mapped to HCPCS/J‑codes; the table rows indicate whether a prior authorization or medical necessity criteria apply for that code.
Prior authorization requirements for listed HCPCS products
For listed HCPCS/J‑code products, the policy associates each product with an HCPCS code and a prior‑authorization/criteria status. Providers should use the HCPCS mapping to confirm whether a given infusion or biologic requires authorization.
- Examples: Zoledronic acid (J3489) — prior authorization not required; Botox (J0585) — prior authorization not required for listed indications; Neulasta (J2506) — prior authorization not required.
- Many biologics and biosimilars are shown with HCPCS codes (e.g., Inflectra Q5103, Renflexis Q5104, Avsola Q5121, Remicade J1745) and a linked criteria/fax form entry.
Prior authorization and HCPCS mapping
HCPCS/J‑code mapping and prior‑authorization notes are presented together; use the HCPCS code in the policy row to locate the corresponding medical necessity criteria and the required fax/prior‑authorization form.
- When the row lists a Link to criteria and Link to fax form, providers must submit the documented clinical information via the specified form.
- If a row shows “Prior authorization is not required,” no prior authorization/fax form is needed for that HCPCS code for the listed indication.
Prior authorization for IV iron
Intravenous iron products have mixed requirements: older formulations often do not need prior authorization while newer IV iron agents (Injectafer, Monoferric, Feraheme) are subject to step‑therapy criteria and require submission of the step therapy documentation.
- No prior authorization required: Ferrlecit (J2916), Sodium ferric gluconate (J2916), Infed (J1750), Venofer (J1756).
- Step therapy / prior authorization required: Feraheme (Q0139/Q0138), Injectafer (J1439), Monoferric (J1437) — see and follow the step therapy criteria and submit the linked fax request form.
Prior authorization for infliximab and biosimilars
Infliximab and its biosimilars have specific guidance: multiple infliximab products are mapped and may be subject to step‑therapy or medical necessity criteria. Follow the linked criteria and fax forms for authorization.
- Examples: Inflectra (Q5103) and Renflexis (Q5104) show links to medical necessity criteria and fax forms; Avsola (Q5121) and Remicade (J1745) may require step therapy or criteria per the product row.
- Unbranded infliximab entries reference J1745 with explicit links to medical necessity criteria and fax request forms — submit required documentation when requested.
Prior authorization requirements (mixed)
Requirements across categories are mixed. Some cytotoxics and supportive care agents explicitly state that prior authorization is not required, while many biologics, immunologics, and specialty infusions reference linked criteria and forms.
- Prior authorization not required examples: Docetaxel (J9171), certain erythropoiesis‑stimulating agents (some Procrit/ Epogen entries).
- Many immunologics/biologics list a Link to criteria and Link to fax form — treat these as authorization required until the row indicates otherwise.
Not explicitly stated in this excerpt
Some rows in the excerpt are incomplete or do not explicitly state prior authorization status. When the policy row lacks a clear prior‑authorization note, providers must consult the linked medical necessity criteria or contact Aetna using the number on the member's ID card before proceeding.
- If a product row does not state “Prior authorization is not required” or list a link to criteria, assume authorization may be required and verify before administration.
- Use the payer resources (website links or provider phone line) when table entries are ambiguous or missing.
Denial risk for step therapy noncompliance
Failure to follow step‑therapy requirements or to obtain required prior authorization may lead to claim denial or non‑coverage. Providers should ensure preferred products and tier‑specific requirements are met before requesting non‑preferred agents.
- Step‑therapy denials can occur if preferred Tier 1 and Tier 2 products are not tried and documented where the policy requires both tiers prior to non‑preferred use (e.g., bone resorption inhibitors, VEGF ophthalmic inhibitors).
- When a product row indicates “Indications subject to step therapy,” follow the referenced step therapy criteria to avoid denials.
IV iron step therapy denial risk
IV iron agents listed with step‑therapy language require adherence to the step‑therapy criteria; absent required trials or documentation, requests for Injectafer, Monoferric, or Feraheme may be denied.
- For Feraheme (Q0139/Q0138), Injectafer (J1439), Monoferric (J1437) — submit the step‑therapy documentation listed in the policy; lack of required prior trials may result in denial.
- For IV iron products without step therapy (e.g., Ferrlecit, Venofer), prior authorization is not required per the product row.
Denial risk for missing medical necessity/step therapy
Coverage decisions frequently depend on medical necessity documentation. Always use the linked medical necessity criteria and the specified fax/prior‑authorization form to submit supporting clinical information.
- Many product rows include Link to criteria and Link to fax form — use those documents when preparing prior‑authorization requests.
- If an entry lists a fax request form, the provider must submit that form with the required clinical details; incomplete forms may delay or deny authorization.
Use linked medical necessity criteria and fax forms
Use the links to medical necessity criteria and the payer's fax request forms for all products that reference them. These documents define indication‑specific requirements, step‑therapy pathways, and required clinical documentation to support authorization.
- Where the table shows Link to criteria — open and follow the medical necessity criteria for the exact indication.
- Where the table shows Link to fax form or “Fax request form” — complete and submit the specified form; many biologics and specialty infusions require this submission.
Submission forms and links
Submission forms and links are provided throughout the policy for many infused and specialty agents. Providers must submit the specified fax request form and reference the HCPCS code and clinical criteria on the form.
- The policy rows that include both an HCPCS code and a Link to fax form indicate that the payer expects the corresponding form for prior‑authorization review.
- Include the HCPCS/J‑code when submitting the fax form to ensure correct routing and adjudication.
Fax form and medical necessity documentation
When a row lists a Fax request form or Link to fax form, that indicates required documentation for prior‑authorization review. Complete clinical fields, attach supporting records, and submit via the method specified on the form.
- Fax forms are the operational mechanism for many prior‑authorization requests in this policy excerpt — incomplete or missing attachments can delay review.
- Follow any form‑specific instructions (e.g., number of prior treatment attempts, lab values, prior response) as detailed in the linked criteria.
Use linked criteria/fax forms
Consolidate: always use the linked criteria and fax forms where provided. These are authoritative — they state whether prior authorization is required, what clinical prerequisites (including step‑therapy) must be met, and what documentation to submit.
- If a product row includes both a criteria link and a fax form link, submit the fax form with the specific evidence requested by the criteria.
- If the product row indicates “Prior authorization is not required,” no fax form is needed for that indication; document the basis in the medical record.
Required documentation and forms
Required documentation and forms are noted at the product level. Providers should not assume coverage; follow the policy row, complete required forms, and supply all clinical documentation to avoid delays or denials.
- Required elements often include the HCPCS/J‑code, indication, prior treatment history, and relevant labs/imaging as specified in the linked criteria.
- When in doubt, contact Aetna via the provider phone number on the member ID or use the website links included in the policy to obtain the correct form or criteria.
Step therapy required for some indications
Step therapy applies to many categories and specific indications in this excerpt. For affected indications, preferred products or multiple tier trials may be required before coverage of non‑preferred agents.
- Examples of indications subject to step therapy: anemia related to zidovudine use (ESAs), multiple bone resorption indications, Crohn's disease, psoriasis, and many immunotherapy/biologic categories.
- Some categories require trying preferred products from both tiers prior to a non‑preferred drug (e.g., VEGF ophthalmic inhibitors, select bone resorption inhibitors).
Step therapy applies to specified indications
Step therapy applies to specified indications; consult the row for the indication and the linked step therapy criteria to confirm required prior agents, trial durations, and documentation.
- Policy lists indications subject to step therapy (for example: Crohn's disease, ulcerative colitis, selected oncology indications, and certain supportive care uses).
- When the row references a Link to criteria for step therapy, adhere to the sequence and evidence requirements there to ensure coverage.
Step therapy for various biologics
Many biologics and immunotherapies are explicitly labeled as “subject to step therapy.” Providers must follow the step therapy pathway in the referenced criteria before requesting non‑preferred biologics.
Step therapy applies to many immunotherapies/biologics
Step therapy applies broadly across many immunotherapies and biologics in this document. For these agents, the policy often requires prior trials of preferred products and submission of linked authorization forms.
- PD‑1/PD‑L1 agents and multiple monoclonal antibodies show indications subject to step therapy (e.g., squamous cell carcinoma, metastatic disease indications).
- Follow the linked criteria for immunotherapy classes to confirm the required sequence of therapy and documentation needed.
Step therapy references
The policy references multiple step‑therapy criteria documents. Treat these references as binding — they describe the required sequence, number of prior agents, and clinical thresholds for coverage decisions.
- When a row shows “Step therapy criteria = Link to criteria,” consult that document for exact trial requirements, timeframes, and exceptions.
- Use the step therapy reference to guide initial prescribing, prior authorization requests, and appeals if coverage is denied.
Initial therapy / preferred-first rules
inv-87: Bone resorption inhibitors initial therapy
Preferred-first requirement for bone resorption inhibitors
Failure to trial preferred agents as indicated may result in denial; see product-level links for exact step therapy/criteria
inv-88: Initial biologic selection
Preferred vs non-preferred biologics — initial selection guidance
Refer to product-level 'Step therapy criteria' links for specific indications and exceptions
Step therapy rules and tables
| Step therapy requirement | Summary |
|---|---|
| Try preferred product(s) first per category before non-preferred product will be covered | |
| Preferred products listed for a category must be used prior to coverage of non-preferred agents; exception process exists for specific cases |
| Applies to indications | Preferred agents / Non-preferred examples |
|---|---|
| Anemia due to Zidovudine use in HIV; transfusion reduction for select surgeries; other anemia indications noted as subject to step therapy | |
| Preferred: Procrit, Aranesp. Non-preferred examples: Epogen, Retacrit, Vafseo (Retacrit referenced HCPCS J0885/Q5106) |
| Product / Indication flagged | Preferred vs non-preferred status |
|---|---|
| Multiple product and indication entries are labeled 'Indications subject to step therapy' (examples include Crohn's disease, ulcerative colitis, gender dysphoria and others) | |
| Document identifies preferred drugs for categories and lists non-preferred alternatives; preferred status shown in product rows while some non-preferred products reference linked step therapy criteria |
| Linked step therapy entries | Implication |
|---|---|
| Multiple products explicitly include 'Step therapy criteria = Link to criteria' such as Avsola, Remicade, unbranded infliximab and some IV iron products (e.g., Feraheme, Injectafer, Monoferric) | |
| Providers must follow the linked step therapy criteria (and submit fax/request forms as indicated) before non-preferred product coverage is approved |
| Categories / agents noted | Step therapy note |
|---|---|
| Numerous categories and agents flagged as 'Indications subject to step therapy' including Rituxan and biosimilars (all requests except rheumatoid arthritis) and PD‑1/PD‑L1 agents (e.g., Keytruda, Opdivo, Tecentriq) for specified indications | |
| Exceptions are listed where applicable (e.g., rheumatoid arthritis excluded for rituximab); many immunotherapy/biologic categories require following step therapy criteria per linked documents |
| Products/categories with external step therapy rules | Reference |
|---|---|
| IV iron products (Feraheme Q0139/Q0138, Injectafer J1439, Monoferric J1437) and some infliximab/biosimilar entries (Avsola Q5121, Remicade J1745) list step therapy criteria as a link to separate criteria documents | |
| Specific step therapy rules and fax request forms are provided via 'Link to criteria' / 'Link to fax form' referenced in the product rows and must be consulted for coverage decisions |
Biosimilar listings and callouts
Policy scope and document notes
This document groups Part B (medically administered) drugs by therapeutic category and identifies preferred and non‑preferred products, maps products to HCPCS/J/Q codes, and indicates applicable utilization management such as step therapy and prior authorization. The listings provide links to product‑specific medical necessity and step therapy criteria and to fax request forms where applicable; providers should use those links when requesting non‑preferred drugs or when PA is required.
Key definitions
Document changes and history
Document copyright year updated to 2025 per Aetna Inc. notice
Policy document version reference updated (document code 4168504-01-01) per Aetna notice
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