Medicare Part B preferred drug list — Aetna Medicare Advantage (MA) only plans
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A preferred drug list for medically administered Medicare Part B drugs under Aetna Medicare Advantage (MA) plans, listing preferred and non-preferred Part B drugs by category, HCPCS codes, and links or notes about medical necessity, step therapy, and fax request forms. Affects providers administering Part B drugs to Aetna MA members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Preferred Product Use
Preferred product use and exceptions
General rule
Step therapy may be applied; specific step therapy criteria are provided via linked criteria documents.
Bone resorption inhibitors — initial therapy
Bone resorption inhibitors
Pamidronate (J2430) and zoledronic acid (J3489) do not require prior authorization; second‑tier products require trial/failure of first‑tier agents and have linked medical necessity/step therapy criteria.
Botulinum toxins — coverage notes
Botulinum toxins
Botox (J0585/J0588) is listed as preferred for these indications with prior authorization not required; other botulinum products (Daxxify J0589, Dysport/Myobloc J0586) are listed with links to criteria or as non‑preferred depending on indication.
Explicit PA coverage statements
Coverage statements for listed products (examples):
See Neulasta entries for PA 'Prior authorization is not required' and 'None' for step therapy.
Refer to Eligard line item for PA status.
See colony stimulating factors (short‑acting) category.
Step therapy groups
Several indications/categories are designated as subject to step therapy:
See the specific category entries and linked step therapy criteria for detailed requirements.
Psoriatic arthritis — formulary placement
Preferred vs non‑preferred listings and step therapy applicability (as presented)
Medical necessity and step therapy links are provided per drug line; follow linked criteria for authorization.
Remicade and biosimilars
Category: Remicade and biosimilars (all other indications)
Medical necessity and step therapy links are provided for infliximab products; providers should follow those linked criteria.
IV iron — indications and authorization
IV iron indications and authorization stance
Some IV iron products require prior authorization or step therapy (see product lines); sodium ferric gluconate (J2916), Infed (J1750), and Venofer (J1756) are noted as not requiring prior authorization.
IVIG/SCIG — product listings
IVIG and SCIG product listing and medical necessity linkage
Providers must follow the linked medical necessity criteria and submission instructions for each product.
Multiple sclerosis / oncology — listings
MS and oncology infused agents and administrative controls
Step therapy and PA status vary by drug; follow the product‑specific line item and links.
Per-drug medical necessity and step therapy requirements
Coverage and authorization depend on drug‑specific medical necessity and step therapy criteria as listed below
Do not assume uniform rules across drugs; consult the product line for exact requirements.
Ophthalmic VEGF inhibitors — non-preferred coverage logic
Covered when product‑specific medical necessity and step therapy requirements are met
Preferred product trials from both tiers are required prior to coverage of non‑preferred ophthalmic VEGF agents.
Prior authorization — product-specific
Product‑specific prior authorization as listed
Check the product line for exact PA wording and the required fax request form.
Product-specific medical necessity and step therapy
Coverage for viscosupplement products is governed by product‑specific medical necessity and step therapy criteria linked in this document.
Links to medical necessity and fax forms are provided for each viscosupplement line item.
This document is a Medicare Part B preferred drug list for Aetna Medicare Advantage (MA) plans that groups physician-administered drugs into therapeutic categories and identifies preferred and non-preferred products. The general rule is that the plan prefers use of designated preferred products and may require trial of a preferred agent before covering a non-preferred product; an exception process exists for members who clinically require a non-preferred product. Product-level entries include links or references to medical necessity criteria, step therapy criteria, and fax request forms as applicable, and providers must follow the linked requirements for authorization and documentation.
Several individual drug entries explicitly state that prior authorization is not required for those products. Examples in the extract include short-acting colony stimulating factors and selected IV iron and oncology agents where the product line shows 'Prior authorization is not required.' Providers should check each product line for the PA designation and follow the provided guidance.
Certain IV iron products are listed with an explicit operational status of no prior authorization required. Specifically, sodium ferric gluconate (J2916), Infed (J1750), and Venofer (J1756) are shown as not requiring prior authorization in the IV iron category; other IV iron products (e.g., Feraheme, Injectafer, Monoferric) reference step therapy or linked criteria.
The extract includes multiple examples where the line item indicates "Prior authorization is not required". Examples shown include Paclitaxel (J9267) and Carboplatin (J9045) in their respective categories, as well as several IV iron agents noted above. When a product line states PA is not required, authorization submission is not needed; confirm coding and documentation requirements for billing.
Ophthalmic anti-VEGF agents are tiered. The policy requires trial of preferred products from both preferred tiers before coverage of a non-preferred ophthalmic VEGF inhibitor. For example, bevacizumab (Avastin) is listed with no PA required in some lines, while non-preferred ophthalmic VEGF agents are restricted until the required preferred-product trials/failures and any product-specific medical necessity criteria are satisfied.
This extract does not present any discrete clinical exclusions labeled as 'excluded' in the fragments provided. The document notes that full exclusions, limitations, and conditions of coverage are described in the plan Evidence of Coverage or in the linked medical necessity criteria; providers should consult those referenced documents for complete exclusion language.
Many non-preferred product entries reference a link to medical necessity criteria or list 'Link to criteria' on the product line. Coverage for non-preferred or restricted products is contingent on meeting the referenced product-specific medical necessity criteria, and providers must submit the required documentation and fax request forms where indicated.
Within the excerpt there are no explicit statements that any drug is categorically 'not medically necessary.' Instead, product lines either reference linked medical necessity criteria or indicate whether prior authorization is required. Clinical determinations of medical necessity are made by applying the linked criteria to the member’s clinical situation.
Paclitaxel (listed as J9267) appears in the extract with the product line showing that medical necessity criteria / prior authorization is not required for that entry, indicating standard coverage without PA for the scenarios shown in this fragment. Always verify the specific product line for the final PA designation.
In this extract no agents are explicitly labeled as 'not medically necessary.' Instead, the document repeatedly uses links to the applicable medical necessity criteria for non-preferred products and indicates whether prior authorization or step therapy applies. Final determinations of 'not medically necessary' are made by applying those linked criteria to the individual case.
Viscosupplement products are listed with product-specific entries that indicate their medical necessity and prior authorization status. For example, the Synvisc line shows "medical necessity is not required" (i.e., prior authorization not required) in the fragment, while other viscosupplements reference links to medical necessity criteria and fax forms. Providers should follow the product-level instructions and submit the referenced fax form when a link to a fax form or PA requirement is shown.
HCPCS / J-code Listings by Category
| J0256 | Prolastin-C, Zemaira (alpha-1 proteinase inhibitors) |
| Q5101 | HCPCS code listed under colony stimulating factors (short-acting) |
| J1447 | HCPCS/J-code listed under colony stimulating factors (short-acting) |
| J1442 | HCPCS/J-code listed under colony stimulating factors (short-acting) |
| Q5110 | HCPCS code listed under colony stimulating factors (short-acting) |
| Q5148 | HCPCS code listed under colony stimulating factors (short-acting) |
| Q5125 | HCPCS code listed under colony stimulating factors (short-acting) |
| J2820 | HCPCS/J-code listed under colony stimulating factors (short-acting) |
| J9217 | Eligard HCPCS/J-code |
| J1950 | Lupron depot HCPCS/J-code |
| J3315 | Trelstar HCPCS/J-code |
| J9202 | Zoladex HCPCS/J-code |
| J9155 | Firmagon HCPCS/J-code |
| J3380 | Entyvio IV HCPCS/J-code |
| Q5103 | Inflectra HCPCS code |
| Q5104 | Renflexis HCPCS code |
| Q9997 | Pyzchiva IV HCPCS code |
| Q5100 | Yesintek IV HCPCS code |
| J9119 | HCPCS code listed under Pemetrexed category |
| J9271 | HCPCS code listed under Pemetrexed category |
| J9299 | HCPCS code listed under Pemetrexed category |
| J9289 | HCPCS code listed under Pemetrexed category |
| J3590/C9399 | Misc codes referenced (multiple products) |
| J9305 | HCPCS code listed |
| J9294 | HCPCS code listed |
| J9296 | HCPCS code listed |
| J9297 | HCPCS code listed |
| J9314 | HCPCS code listed |
| J7320 | GenVisc (HCPCS code as listed) |
| J7321 | Hyalgan; Supartz FX; Visco-3 (HCPCS code as listed) |
| J7322 | Hymovis (HCPCS code as listed) |
| J7323 | Euflexxa (HCPCS code as listed) |
| J7324 | Orthovisc (HCPCS code as listed) |
| J7325 | Synvisc (HCPCS code as listed) |
| J7328 | Gelsyn-3 (HCPCS code as listed) |
| J7329 | TriVisc (HCPCS code as listed) |
| J7331 | Synojoynt (HCPCS code as listed) |
| J7332 | Triluron (HCPCS code as listed) |
Prior Authorization, Step Therapy, and Submission Requirements
Prior authorization expectations
Prior authorization expectations: Requirements vary by drug and indication. Some products (including many IV and specialty agents) require prior authorization before administration; others explicitly state “prior authorization is not required.” When PA is required, providers must follow the associated medical-necessity criteria and submit the specified fax request form or electronic request as noted on Aetna’s criteria pages.
- Check the product-specific entry for PA status (e.g., “Prior authorization is not required” vs. “Prior authorization”).
- If PA is required, use the linked medical necessity criteria and the listed fax request form.
Prior authorization varies by drug
Prior authorization varies by drug and product class. Examples in this document show that some short-acting and long-acting colony stimulating factors, certain bisphosphonates, carboplatin, select oncology agents, and many ophthalmic VEGF inhibitors have mixed PA status across preferred vs non-preferred products.
- Always verify the HCPCS/NDC-level entry for the specific product (preferred vs non-preferred).
- Preferred products often have no PA; non-preferred products are more likely to require PA.
Prior authorization requirement (product-specific)
Product-specific prior authorization requirements: follow the line-item entry for each drug. The policy lists PA status and provides a link to medical necessity criteria and a fax request form where applicable.
- Examples: • Zoledronic acid (J3489) — prior authorization is not required. • Carboplatin (J9045) — prior authorization is not required. • Docetaxel (J9171) — prior authorization required. • Durolane (J7318) — prior authorization required. • Euflexxa (J7323) — prior authorization required.
- When a product is effective-dated (e.g., new HCPCS or misc codes effective 4/1/2026), check the posted criteria on the effective date.
Prior authorization requirement for viscosupplements
Viscosupplements: PA and documentation requirements differ by product and by single- vs multiple-injection formulations. Several viscosupplements require prior authorization and the associated fax form; others do not.
- Single-injection products (examples): Durolane (J7318) — PA required; Synvisc-one (J7325) — PA not required.
- Multiple-injection products (examples): Euflexxa (J7323) — PA required; Synvisc (J7325) — PA not required.
- Use the product entry to locate the linked medical necessity criteria and the fax request form.
Step therapy requirement
Step therapy requirement: Many drug classes use step therapy — providers must try preferred products first (tiered preferred requirements) before a non-preferred agent will be covered. An exceptions process exists for clinical situations that justify bypassing the step.
- Step therapy applies to multiple classes (e.g., VEGF inhibitors, bone resorption inhibitors, select biologics).
- Preferred-product trial from one or both tiers may be required prior to non-preferred coverage.
- Providers may request an exception when medically necessary; follow the documented exception process on Aetna’s site.
Step therapy applicability
Step therapy applicability and examples: the policy identifies indications that are subject to step therapy and links to the specific step therapy criteria for each product or indication.
- Examples of indications subject to step therapy include: osteoporosis, psoriatic arthritis, ulcerative colitis, iron deficiency anemia (after oral iron trial or intolerance), certain oncology indications, and ophthalmic VEGF use.
- For many biosimilars and infliximab products, preferred biosimilars are listed and step therapy may require trial of preferred biosimilars before non-preferred originator or non-preferred biosimilars.
Step therapy requirements for VEGF inhibitors
Step therapy requirements for VEGF inhibitors (ophthalmic): Preferred products from both tiers may be required before a non-preferred VEGF inhibitor will be approved. Providers should confirm whether a preferred-product trial is mandated for the patient’s indication.
- Bevacizumab (Avastin) for ophthalmic use is listed as preferred in many cases and often does not require PA.
- Non-preferred ophthalmic VEGF agents may require documentation of trial/failure of preferred products and submission of the fax request form.
Denial triggers (inferred)
Denial triggers and denial risk: Requests missing required documentation, lacking evidence of step-therapy trial (when applicable), or for non-preferred products with no documented exception are at higher risk for denial.
- Common denial triggers: absent or incomplete medical necessity documentation, failure to document prior trial of preferred product when step therapy applies, and submission without the required fax form or criteria reference.
- Non-preferred products commonly carry higher PA/denial risk if preferred alternatives were not tried or an exception was not justified.
Submission documentation
Submission documentation: Providers must submit product-specific medical necessity documentation and the designated fax request form (or follow the electronic submission process) and reference the linked criteria in the request.
- Include clinical history, prior therapies and responses, relevant lab/imaging results, and rationale for using a non-preferred product if applicable.
- Reference the exact Aetna medical necessity criteria link shown in the policy entry; attach or fax the product-specific request form listed on the same entry.
Provide linked criteria and fax form
Provide linked criteria and fax form: When the drug entry includes a link to medical necessity criteria and a fax request form, providers must supply both in the PA submission to avoid processing delays.
- Locate the criteria and fax form links in the drug’s line-item entry on the Part B preferred drug list.
- If the entry states “Prior authorization is not required,” no fax form is necessary; otherwise submit the listed form.
Submit product-specific medical necessity and fax form
Submit product-specific medical necessity documentation and fax form: Use the product’s HCPCS and the policy’s specified fax request form. For products with effective-dated updates, submit the form and supporting documentation consistent with the effective date and posted criteria.
- When submitting, include HCPCS code, diagnosis, prior treatment(s), dates, and justification for the requested drug.
- For newly added products (e.g., entries effective 4/1/2026), check that the criteria and form are posted before submitting or follow the guidance to submit on/after the effective date.
Initial Therapy Preferences and Authorization
Bone resorption — initial therapy
First‑line preferred agents for bone resorption indications
Initial therapy preferences
Preferred vs non‑preferred listing and prior authorization expectations
Follow the specific drug line for PA and step therapy status.
Initial therapy authorization
Initial coverage actions referenced
Some viscosupplement products are noted as prior authorization not required (e.g., Synvisc in the fragment); verify the product line item.
Step Therapy Rules and Required Trials
| Rule | Notes / source |
|---|---|
| Preferred-first step therapy | |
| Preferred products should be used prior to non-preferred products; an exception process exists for cases requiring a non-preferred product. Specific step therapy criteria are provided via linked criteria documents. |
| Example agent / indication | Step therapy note |
|---|---|
| Anemia due to Zidovudine use (Procrit preferred / Epogen non-preferred) | |
| Ulcerative colitis (Entyvio, Inflectra, Renflexis listed; step therapy criteria: None for listed preferred biologics) | |
| Iron deficiency anemia (IV iron) — after intolerance to oral iron or CKD; some IV iron products (e.g., sodium ferric gluconate J2916, Infed J1750, Venofer J1756) have 'Prior authorization is not required' while others reference step therapy criteria. |
| Drug / category | Step therapy linkage / per-drug note |
|---|---|
| Psoriatic arthritis — Inflectra, Renflexis, Simponi Aria (preferred) vs Avsola, Remicade, Cimzia, Orencia (non-preferred) | |
| Remicade and biosimilars — Inflectra (Q5103) and Renflexis (Q5104) listed as preferred alternatives; Remicade (J1745) listed as non-preferred with links to medical necessity/step therapy. | |
| IV iron — multiple products listed with product-specific notes; some require step therapy criteria (e.g., Feraheme, Injectafer, Monoferric) and others do not. | |
| MS / oncology infused agents (e.g., Phesgo, Perjeta, Docetaxel) — step therapy status varies by product; per-drug medical necessity and step therapy links provided. |
| Product | Step therapy status |
|---|---|
| Inflectra (Q5103) | |
| Neulasta / Neulasta Onpro (long-acting G-CSF) — preferred listing; per-line shows 'Prior authorization is not required' for some agents | |
| Docetaxel (J9171) — medical necessity: Prior authorization; step therapy: per product listing |
| Requirement | Details / example |
|---|---|
| Tiered preferred-product trial required | |
| For certain categories (e.g., bone resorption inhibitors), trial of first-tier preferred agents (pamidronate J2430 or zoledronic acid J3489) is required before second-tier or non-preferred agents are covered; pamidronate and zoledronic acid do not require prior authorization. |
| VEGF/ophthalmic rule | Coverage implication |
|---|---|
| Preferred products from both tiers required before non-preferred ophthalmic VEGF inhibitor | |
| Coverage for a non-preferred ophthalmic VEGF inhibitor requires prior trial/failure of preferred product(s) from both tiers; product-specific medical necessity criteria and step therapy links must be satisfied (examples: Bevacizumab/Avastin, Eylea, Byooviz listed with tiered preferred requirements). |
Administration and Infusion Settings
Infusion center — implied site‑of‑care
Infused biologics are listed with HCPCS/J‑codes implying administration in infusion settings (infusion center); providers should bill and document administration in the appropriate setting.
Biosimilar Preferences and Related Notes
Neupogen — non‑preferred; Zarxio preferred
Zarxio is listed as the preferred short‑acting G‑CSF while Neupogen is listed as non‑preferred; follow the formulary preference and linked criteria when selecting agents.
- Zarxio: listed as preferred (HCPCS Q5101).
- Neupogen and other short‑acting G‑CSFs are listed as non‑preferred with links to criteria.
Remicade / unbranded infliximab — linked criteria
Remicade and unbranded infliximab are listed with linked medical necessity and step therapy criteria; biosimilars are shown as preferred alternatives in many categories—use the listed HCPCS/J‑codes and linked criteria when requesting coverage.
Mvasi (Q5107) — Avastin biosimilar listing
Mvasi (Q5107) is listed with a link to medical necessity criteria and appears as a preferred bevacizumab biosimilar in some oncology entries; follow the linked criteria and use the listed HCPCS codes when requesting coverage.
- Mvasi (Q5107): “Medical necessity criteria = Link to criteria” and “Fax request form = Link to fax form.”
- Preferred biosimilar status is shown in bevacizumab/biosimilar groupings—use the product’s HCPCS Q‑code when billing.
Bevacizumab/ophthalmic biosimilars — trial preferred first
Ophthalmic bevacizumab biosimilars and other VEGF agents are tiered; preferred agents (including listed biosimilars) must be trialed prior to non‑preferred products—follow the product HCPCS/Q‑codes and linked medical necessity.
Definitions and Category Notes
Background and Scope
The document groups Medicare Part B administered drugs into categories and identifies preferred and non-preferred products for Aetna MA plans. It emphasizes that coverage decisions for many listed products depend on meeting the linked medical necessity criteria and any applicable step therapy rules; providers are directed to the linked criteria and fax forms for each product and to the plan Evidence of Coverage for full benefit details.
Policy Revision History
Document footer shows copyright year 2025.
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