Aetna Medicare Advantage Part B preferred drugs

Coverage criteria and product-specific rules

inv-01: Bone resorption inhibitors - initial coverage logic

Preferred products and step therapy rules for bone resorption inhibitors

Bone resorption inhibitors preferred-before-nonpreferred: Preferred product from both tiers required prior to receiving a non-preferred product for listed indications (hypercalcemia of malignancy; prevention of skeletal events in multiple myeloma; prevention of skeletal events in prostate cancer or solid tumors with bone metastases; treatment of osteopenia or osteoporosis in systemic mastocytosis)

Specific product-level step therapy criteria and links provided per drug

inv-02: Alpha-1 proteinase inhibitors

Alpha-1 antitrypsin deficiency products

Alpha-1 products: Preferred products Prolastin-C and Zemaira (HCPCS J0256) are listed with links to medical necessity criteria and fax forms; other alpha-1 products (e.g., Aralast NP) are listed as non-preferred with criteria links

Indication subject to step therapy; linked criteria referenced

inv-03: Botulinum toxins

Botulinum toxin coverage notes

Botulinum toxins: Botox (J0585) and Xeomin (J0588) are noted as 'Prior authorization is not required' for listed indications (blepharospasm, cervical dystonia, chronic sialorrhea, upper limb spasticity); other botulinum products (Daxxify, Dysport, Myobloc) are non-preferred or require criteria/links

Specific product-level step therapy or criteria links provided per product

inv-04: Colony stimulating factors

Colony stimulating factors

CSFs: Neulasta (J2506) and biosimilar Fulphila (Q5108) are listed with 'Prior authorization is not required'; other colony stimulating factors and biosimilars are listed with links to medical necessity criteria and may have step therapy as indicated

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

Erythropoiesis stimulating agents - preferred vs non-preferred: Preferred drugs include Procrit and Aranesp; non-preferred drugs include Epogen and Retacrit (HCPCS J0885 listed) and other alternatives. Some products (e.g., Reblozyl) have linked criteria and fax forms.

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

Prior authorization indicated: Aranesp (J0881) is noted as 'Prior authorization' under medical necessity criteria; Procrit (J0885) is shown as 'Prior authorization is not required' in this excerpt; Reblozyl and other products reference 'Link to criteria' and 'Link to fax form' for medical necessity documentation.

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).

Step therapy applicability: Entries are flagged as 'Indications subject to step therapy' for multiple conditions (examples include Crohn's disease, ulcerative colitis, psoriasis and other immunologic indications); coverage requires meeting the product-specific step therapy or medical necessity criteria linked for each drug.

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

IV iron coverage criteria: Patient has iron deficiency anemia AND either intolerance to oral iron or unsatisfactory response to oral iron OR has chronic kidney disease

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

Preferred biosimilars: Inflectra (Q5103) and Renflexis (Q5104) are listed with links to medical necessity criteria and fax forms and are identified as preferred in multiple indications; Avsola (Q5121) and Remicade (J1745) are listed with criteria links and may have step therapy noted per indication

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.

PA not required examples: Some agents are explicitly noted as 'Prior authorization is not required' in this excerpt (examples include Docetaxel J9171, Carboplatin J9045, select pemetrexed codes, and other chemotherapy/infusion agents); other agents list 'Prior authorization' or link to criteria indicating PA is 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

Rituximab step therapy: All requests for rituximab and biosimilars are subject to step therapy except requests for rheumatoid arthritis, which are excluded from step therapy

Document explicitly lists the rheumatoid arthritis exception for rituximab

inv-12: Ophthalmic VEGF inhibitor tiering

Coverage and prior authorization notes for categories and products

VEGF inhibitors (ophthalmic) tiering: Preferred product from both tiers must be used prior to receiving a non-preferred ophthalmic VEGF product; bevacizumab (Avastin) is noted as 'Prior authorization is not required' while tiered preferred ophthalmic biologics (e.g., Byooviz) are listed for trial/failure sequencing

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

Prior authorization presence: Some products explicitly state 'Prior authorization is not required' (for example bevacizumab/Avastin and selected pemetrexed codes), while others list 'Prior authorization' or provide 'Link to criteria' indicating that authorization may be required; providers should review individual product rows for specifics

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

Alpha-1 proteinase inhibitors - Preferred HCPCSHCPCSCovered

J0256

Prolastin-C, Zemaira (alpha-1 proteinase inhibitors)

Bone resorption inhibitors - mixed tiersHCPCSCovered

J2430	Pamidronate
J3489	Zoledronic acid
J0897	Xgeva

Botulinum toxinsHCPCSCovered

J0585	Botox
J0588	Xeomin
J0589	Daxxify
J0586	Dysport
J0587	Myobloc

Complement inhibitors / related biologicsHCPCSCovered

J1299	Soliris (eculizumab)
J1303	Ultomiris (ravulizumab)
J1823	Uplizna
J9332	Vyvgart
J9334	Vyvgart Hytrulo

Colony stimulating factors (long and short-acting) and biosimilarsHCPCSCovered

J2506	Neulasta / Neulasta Onpro
Q5108	Fulphila
J1447	Granix
J1442	Neupogen

Erythropoiesis stimulating agents and related productsHCPCSCovered

J0885	Epoetin products (Epogen/Procrit/Retacrit)
J0882	Reblozyl (luspatercept) HCPCS listed

Erythropoiesis stimulating agents - Procrit/RetacritHCPCS

J0885	Procrit / Retacrit HCPCS code J0885 (as listed)
Q5106	Q5106 (listed alongside J0885)

Aranesp / Reblozyl and related HCPCS entriesHCPCS

J0881	Aranesp HCPCS code J0881
J0882	Reblozyl HCPCS code J0882/J0881 (listed together in header)
J0896	Reblozyl HCPCS code J0896 (also referenced)
Q4081	Q4081/J0885 (listed)
Q5105	Q5105/Q5106 (listed)
J0901	J0901 (listed)

Enzyme replacement and Factor VIII codesHCPCS

J1786	Cerezyme HCPCS code J1786
J3060	Elelyso HCPCS code J3060
J7211	Kovaltry HCPCS code J7211
J7209	Nuwiq HCPCS code J7209
J7192	Advate HCPCS code J7192
J7210	Afstyla HCPCS code J7210
J7182	NovoEight HCPCS code J7182
J7185	Xyntha HCPCS code J7185

Geographic atrophy product codesHCPCS

J2782	Izervay HCPCS code J2782
J2781	Syfovre HCPCS code J2781

HCPCS / J / Q codes mapped to products in excerptHCPCS

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)

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Biologics entriesHCPCS

J3380	Listed repeatedly in product rows (site/admin code context)
Q5103	Inflectra HCPCS code
Q5138	Wezlana HCPCS code
Q5134	Tyruko HCPCS code

Infliximab and biosimilarsHCPCS

J2323	Tysabri (listed)
Q5104	Renflexis HCPCS code
Q5121	Avsola HCPCS code
J1745	Remicade / unbranded infliximab HCPCS code

Intravenous ironHCPCSCovered

J1439	Injectafer HCPCS code
J1437	Monoferric HCPCS code
Q0139	Feraheme HCPCS code
Q0138	Feraheme variant HCPCS code
J2916	Ferrlecit / sodium ferric gluconate HCPCS code
J1750	Infed HCPCS code
J1756	Venofer HCPCS code

IVIG productsHCPCS

J1561	Gammaked / Gamunex-C HCPCS code
J1459	Privigen HCPCS code
J1552	Alyglo HCPCS code
J1554	Asceniv HCPCS code
J1556	Bivigam HCPCS code
J1572	Flebogamma HCPCS code
J1569	Gammagard Liquid / S/D HCPCS code
J1557	Gammaplex HCPCS code
J1568	Octagam HCPCS code
J1576	Panzyga HCPCS code

SCIG and multiple sclerosis therapiesHCPCS

J1559	Hizentra HCPCS code (SCIG)
J1558	Xembify HCPCS code (SCIG)
J1551	Cutaquig HCPCS code (SCIG)
J1555	Cuvitru HCPCS code (SCIG)
J1575	HyQvia HCPCS code (SCIG)
J2350	Ocrevus HCPCS code
J2351	Ocrevus Zunovo HCPCS code
J2329	Briumvi HCPCS code
J0202	Lemtrada HCPCS code

Immune globulins / SCIG (examples in excerpt)HCPCS

J1559	Hizentra
J1558	Xembify
J1551	Cutaquig
J1555	Cuvitru
J1575	HyQvia
J1569	Gammagard Liquid

Multiple sclerosis agents (examples)HCPCS

J2350	Ocrevus
J2329	Briumvi
J0202	Lemtrada
J2323	Tysabri

Breast cancer / Avastin biosimilars (examples)HCPCS

J9316	Phesgo
J9306	Perjeta
Q5107	Mvasi
Q5118	Zirabev
J9035	Avastin
Q5107	Mvasi (repeat)

Taxane chemotherapiesHCPCS

J9267	Paclitaxel
J9264	Abraxane
J9171	Docetaxel

Mixed oncology agents and category placeholdersHCPCS

J9033	Category placeholder (multiple agents grouped under J9033 in document)
J9058	Bendamustine
J9056	Vivimusta
J9045	Carboplatin
J9174	Beizray
J9172	Docivyx

Herceptin and biosimilars groupHCPCS

Q5117	Kanjinti
Q5112	Ontruzant
J9355	Herceptin
Q5146	Hercessi
Q5113	Herzuma
Q5114	Ogivri

Rituximab and multiple myeloma / other oncology agentsHCPCS

Q5119	Riabni / Rituxan group placeholder
Q5123	Riabni (alternate code listed)
J9312	Rituxan
J9311	Rituxan Hycela
J9179	Halaven
J9352	Yondelis

Multiple myeloma agentsHCPCS

J9046	Bortezomib / Velcade
J9047	Kyprolis
J9145	Darzalex
J9144	Darzalex Faspro
J9176	Empliciti
J9227	Sarclisa

PD-1/PD-L1 immunotherapy agentsHCPCS

J9119	Libtayo / PD-1/PD-L1 group placeholder
J9271	Keytruda
J9299	Opdivo
J9289	Opdivo Qvantig
J9022	Tecentriq
J9024	Tecentriq Hybreza

Pemetrexed / antifolate agentsHCPCS

J9305	Alimta
J9294	Pemetrexed
J9296	Pemetrexed (other codes listed)
J9297	Pemetrexed (other codes listed)
J9314	Pemetrexed (other codes listed)
J9304	Pemfexy

Pemetrexed / AlimtaHCPCS

J9305	Alimta
J9294	Pemetrexed (one of listed codes)
J9296	Pemetrexed (one of listed codes)
J9297	Pemetrexed (one of listed codes)
J9314	Pemetrexed (one of listed codes)

Ophthalmic/VEGF inhibitors and related biologicsHCPCS

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)

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Viscosupplements (single and multiple injection)HCPCS

J7318	Durolane
J7325	Synvisc-one / Synvisc
J7326	Gel-one
J7327	Monovisc
J7322	Hymovis One / Hymovis
J7323	Euflexxa
J7328	Gelsyn-3
J7320	GenVisc
J7321	Hyalgan / Supartz FX / Visco-3 (same code used)
J7324	Orthovisc

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Severe asthma, somatostatin analogues, systemic lupus biologicsHCPCS

J0517	Fasenra
J2356	Tezspire
J2357	Xolair
J2786	Cinqair
J2182	Nucala
J1930	Somatuline depot
J2353	Octreotide acetate depot / Sandostatin LAR
J2502	Signifor LAR
J0490	Benlysta
J0491	Saphnelo

Oral iron trial — After intolerance to oral iron or unsatisfactory response to oral iron

Trigger for IV iron coverageAfter intolerance to oral iron or unsatisfactory response to oral iron

What providers must do (authorization, forms, step therapy)

Prior Authorization

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

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.

Initial therapy / preferred-first rules

inv-87: Bone resorption inhibitors initial therapy

Preferred-first requirement for bone resorption inhibitors

Preferred-first: Preferred drugs from the specified tiers (e.g., pamidronate J2430, zoledronic acid J3489 and designated tier 2 preferred agents) must be used prior to coverage of non-preferred bone resorption inhibitors; Xgeva and other agents have linked criteria for step therapy when applicable

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

Preferred biologics: Preferred infliximab biosimilars such as Inflectra (Q5103) and Renflexis (Q5104) are listed with linked medical necessity criteria and typically have no step therapy for some indications; non-preferred biologics or biosimilars (e.g., Avsola where designated) may be subject to step therapy per the linked criteria

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

Note

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

Step therapy — A utilization management requirement that a preferred drug must be tried before a non-preferred alternative will be covered.

DefinitionA utilization management requirement that a preferred drug must be tried before a non-preferred alternative will be covered.

PurposeEnsure preferred products are used first; exception process exists for patients who require a non-preferred product.

Where to find specific rulesSee corresponding step therapy criteria document on the Aetna website for product- and indication-specific requirements.

Prior authorization — Administrative requirement indicated for many specialty infused drugs in this section; referenced by 'Prior authorization is not required...'

DefinitionAdministrative requirement indicated for many specialty infused drugs; entries show 'Prior authorization is not required' or link to criteria when PA is required.

Document changes and history

2025-01-01revision

Policy document version reference updated (document code 4168504-01-01) per Aetna notice

OpenPayer

Medicare Part B preferred drug list — Aetna Medicare Advantage (MA) only plans