Medicare Part B preferred drug list (MAPD only)
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Lists medically administered Part B drugs with preferred and non-preferred products and notes when step therapy or prior authorization applies for Aetna Medicare Advantage plans that include prescription drug coverage (MAPD). Affects providers prescribing/administering Part B drugs for Aetna MAPD members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Category Rules
Bone resorption inhibitors - step therapy
Covered when ALL of the following are met for indicated conditions (summary from list):
See linked criteria per product
Alpha-1 proteinase inhibitors - step therapy
Covered when ALL of the following are met (alpha-1 antitrypsin deficiency example):
HCPCS J0256/J0257 listed per product
Neuromuscular and complement inhibitor coverage
Covered when ALL of the following are met for neuromuscular and complement-related indications (examples):
Indications include cervical dystonia and blepharospasm; see per-drug links for criteria
See product-specific links for exact requirements
Supportive care agents coverage
Covered when ALL of the following are met for supportive care agents:
Indications include anemia due to zidovudine in HIV and transfusion reduction for select surgeries; see links per product
General coverage grouping (document references external criteria links)
Covered when administrative and clinical criteria (linked) are met; some products are preferred and some are non-preferred with step therapy or prior auth requirements.
See chunks 19 and 29 for examples.
See multiple product entries where criteria links and fax forms are referenced.
Category-level coverage and access rules (summary)
Coverage, step therapy, and prior auth rules vary by drug and category; see linked criteria for full clinical requirements.
See individual product lines for prior auth or step therapy status.
Applies to multiple ophthalmic VEGF inhibitors (examples: Avastin/Bevacizumab, Byooviz, Eylea, Beovu, Lucentis, Cimerli, etc.).
Other products reference linked criteria/fax forms and may require prior authorization.
See the per‑drug entries and links for exact sequencing and exceptions.
Step therapy and administrative coverage rules (general)
Covered when ALL of the following are met
Applies across ophthalmic VEGF inhibitors and many viscosupplements as indicated
Some products explicitly state prior authorization is not required; others require fax forms and criteria links.
Part D vs Part B routing
See product entries for Part D routing and request instructions.
General coverage condition
Coverage available when product-specific medical necessity and step therapy criteria are met (see linked criteria); some agents are Part D not Part B.
See product‑specific links and fax forms in the full policy for exact requirements.
The policy groups drugs into preferred and non-preferred listings and applies step therapy where indicated. For classes with tiered preferences, a non-preferred product will generally only be covered after documented trial and failure of the preferred agent(s). Examples in the bone resorption inhibitor category show preferred products and linked medical necessity/step therapy criteria; where a product is non-preferred the listing references step therapy or prior authorization criteria that must be satisfied before coverage is approved.
When an entry is labeled non-preferred or when an item is listed as for "All other indications," the policy indicates that those uses are subject to step therapy. Providers should expect that coverage for non-preferred agents or for indications listed as subject to step therapy requires adherence to the referenced step therapy/medical necessity links and any fax request forms before approval.
For ophthalmic VEGF inhibitors, the policy requires trial of preferred products from both tiers before a non-preferred ophthalmic VEGF agent will be approved. The listing explicitly states a preferred product from both tiers is required prior to receiving a non-preferred product, and product lines include links to step therapy criteria and fax forms that must be followed for coverage.
Some viscosupplements and selected single-injection agents are documented as "Prior authorization is not required" for specific products in the list (for example, Durolane and Synvisc/Synvisc-one entries note prior authorization not required). Where the entry states no prior authorization is required, those products may be administered without submitting a PA request according to the table entry.
Certain agents are routed to the pharmacy benefit or otherwise excluded from Part B. Entries that indicate "See Part D benefit" or list HCPCS as "Not applicable" (for example, some SC formulations or indications) are not handled under this Part B policy and should be processed under the Part D benefit or per the instructions in the product-specific entry.
When an entry explicitly states "Prior authorization is not required", that indicates the product is routingly covered without submission of a prior authorization for the specified HCPCS-coded product. Examples in this document include zoledronic acid and some viscosupplements where the table cell states prior authorization is not required; providers may bill those products without a PA per the listing.
This partial document does not list detailed not medically necessary (NMN) rules. Explicit NMN determinations and clinical criteria are maintained in separate medical necessity documents referenced by the links in the listings. For specific NMN language, providers should consult the corresponding medical necessity criteria linked for each product.
HCPCS / J-code / Code Listings
| J0885 | Procrit / Epogen (erythropoiesis-stimulating agents) |
| J0896 | Reblozyl |
| J0179 | Beovu (VEGF inhibitor, ophthalmic) |
| Q5128 | Cimerli (VEGF inhibitor, ophthalmic) |
| J7318 | Durolane (viscosupplement) |
| J7325 | Synvisc-one / Synvisc (viscosupplement) |
| J7326 | Gel-one (viscosupplement) |
| J7327 | Monovisc (viscosupplement) |
| J7322 | Hymovis One / Hymovis (viscosupplement) |
| J7323 | Euflexxa (viscosupplement) |
| J7320 | GenVisc (viscosupplement) |
| J7321 | Hyalgan / Supartz FX / Visco-3 (viscosupplements) |
| J7324 | Orthovisc (viscosupplement) |
| J7328 | Gelsyn-3 (viscosupplement) |
Prior Authorization, Step Therapy, and Submission Requirements
Prior authorization varies by drug — some products show PA not required
Many listed drugs show that prior authorization is not required for specific products (example: Botox J0585; Zarxio Q5101; Neulasta J2506 entries indicate PA status). Providers should verify per-drug PA guidance and follow any linked instructions where present.
Some products explicitly list prior authorization as not required
Several individual product entries explicitly state “Prior authorization is not required” (for example: Procrit J0885, Ferrlecit J2916, Eligard J9217, Firmagon J9155). Providers should confirm PA status for the specific HCPCS/J code they will bill.
PA requirements differ — some entries point to linked criteria/fax forms
Many entries alternate between explicitly stating PA is not required and referencing external medical necessity or step therapy criteria with a fax request form. Providers must follow the per-product guidance: if a “Link to criteria” or “Link to fax form” is present, submit per that guidance.
- When a product line shows “Link to criteria” or “Link to fax form,” use those linked medical necessity/step therapy documents and fax request forms.
- When a product line shows “Prior authorization is not required,” no PA submission is listed for that product in this document.
Prior authorization for viscosupplements/selected HCPCS products — varies by product
Viscosupplements and selected HCPCS-coded agents have mixed PA expectations: some (e.g., Durolane, Synvisc-one) show prior authorization is not required, while other viscosupplements reference medical necessity or step therapy links and may require PA submissions.
Prior authorization requirement — reference product-specific criteria and fax forms
Many products listed require prior authorization per Aetna medical necessity and/or step therapy criteria; PA requests should reference the specific HCPCS/J or Q code and use the product-specific fax request form when indicated.
- Include the product HCPCS/J or Q code on PA requests as shown in the product line (examples shown across chunks 72, 78, 81).
- If a product line includes “Link to fax form” or “Link to criteria,” submit documentation per those linked forms.
Step therapy — try preferred product(s) first; exception process available
Step therapy requires that preferred products be tried first; an exception process exists for clinical reasons. Providers must follow the step therapy criteria in the linked documents if the product or indication is marked subject to step therapy.
- The policy defines step therapy as requiring preferred drugs be tried before non-preferred alternatives (see policy overview).
- An exception process is available for specific clinical cases that may call for a non-preferred product.
Step therapy applies to many listed indications — follow per-drug criteria
Step therapy is applied across many indications and product categories; multiple entries are labeled “Indications subject to step therapy” or reference ‘Step therapy criteria’ links that must be followed for coverage.
- Examples include erythropoiesis stimulating agents, enzyme replacement therapy, and IV iron products — see each product’s ‘Link to criteria’ for required trials.
- Providers must document trials/failures as required by the linked step therapy criteria.
Step therapy applicable for many indications — linked criteria define required trials
Multiple categories and specific indications are subject to step therapy; several product lines explicitly point to “Step therapy criteria” links that define required prior trials and sequencing.
- Rituximab entries note step therapy applies to all requests except rheumatoid arthritis — follow the linked step therapy criteria.
- Ophthalmic VEGF inhibitors and many oncology and immunologic agents are marked subject to step therapy; use linked documents for specifics.
Step therapy required for many VEGF inhibitors and viscosupplements — preferred-tier trials required
For ophthalmic VEGF inhibitors and many viscosupplements, step therapy requires trial of a preferred product from both tiers before coverage of a non-preferred product; follow the product-specific step therapy links and fax forms.
- Ophthalmic VEGF inhibitor examples: Byooviz (Q5124), Eylea (J0178), Beovu (J0179), Lucentis (J2778) — each notes preferred-tier requirements and links to step therapy criteria and fax forms.
- Viscosupplement examples: Durolane (J7318), Synvisc-one (J7325) — entries show mixture of ‘not required’ and linked criteria; follow the line-item guidance.
Follow linked step therapy criteria documents for specifics
When an item is marked subject to step therapy, providers must follow the linked step therapy criteria documents for the specific required prior trials, acceptable failures, and any documentation requirements.
- Linked documents contain the exact trial durations, acceptable failure definitions, and documentation templates.
- If the product is routed to Part D per the entry, follow the Part D routing instructions in the linked criteria.
Use linked medical necessity criteria and fax request forms where indicated
Many product entries include a “Link to criteria” and a “Link to fax form”; providers must use those medical necessity criteria and fax request forms when submitting prior authorization or step therapy exception requests.
- If a product line shows a fax request form link, use that form for PA submissions as indicated.
- When a ‘Link to criteria’ is present, supply the clinical documentation described in that external criteria document.
Procrit (J0885) — prior authorization not required (example)
Procrit (J0885) is listed in the erythropoiesis stimulating agents grouping and is noted specifically as “Prior authorization is not required.” Providers administering Procrit do not need to submit a PA per this listing.
- Procrit entry: “Prior authorization is not required.”
- No fax request form is indicated for Procrit in this entry.
Many entries include links to medical necessity criteria and fax forms — use them for submissions
Many product entries reference both a ‘Link to medical necessity criteria’ and a ‘Link to fax form,’ indicating that providers must submit the specified fax request and meet the linked clinical criteria for approval.
- Examples include bevacizumab/Avastin and its biosimilars (links to criteria and fax forms) and multiple oncology biologics with fax forms referenced.
- Where a fax form link is shown, use that form to submit prior authorization requests.
Fax request forms and criteria links present for multiple products (examples: Beovu, Cimerli, Lucentis)
Specific products list a fax request form or medical necessity link on their line (examples: Beovu, Cimerli, Lucentis), and providers should use those fax forms and criteria links when submitting authorization requests.
Submission and documentation — use referenced fax forms and criteria links
Providers must submit PA or step therapy exception requests using the referenced fax request forms and include documentation that meets the linked medical necessity or step therapy criteria for the product and indication.
- Include the HCPCS/J/Q code for the specific product on the request as shown in the product line.
- Attach clinical documentation consistent with the linked medical necessity or step therapy criteria.
Denial risk — step therapy not followed can trigger denial
Failure to follow step therapy requirements may result in denial of coverage; the policy states coverage may be denied if step therapy is not followed where it applies.
- Step therapy requires trying preferred products first; lacking documented trials/failures per criteria may lead to noncoverage.
- Use the exception process when clinically appropriate and document reasons per the linked criteria.
Step therapy may trigger denial for select IV iron products — follow linked criteria
Select IV iron products (Feraheme Q0139/Q0138, Injectafer J1439, Monoferric J1437) reference step therapy criteria; providers should document required prior trials or indications per those links to avoid possible denial.
Preferred-tier requirement for ophthalmic VEGF inhibitors — trial of preferred products from both tiers required
Use of non-preferred ophthalmic VEGF inhibitors requires documented trial and failure of preferred products from both tiers prior to coverage of a non-preferred product; follow the product-specific step therapy links and include required documentation on the fax form.
- Examples: Beovu, Eylea, Byooviz, Lucentis entries all note the two-tier preferred-product requirement and link to step therapy criteria/fax forms.
- Document trials of preferred products from both tiers as required by the linked criteria.
Step therapy general requirement — missing required trials may lead to denial
Prescribers may be denied coverage if step therapy prerequisites are not met; the policy emphasizes that a preferred product from both tiers is required prior to receiving a non-preferred product for listed indications.
- This general step therapy rule applies across multiple categories (ophthalmic VEGF inhibitors, viscosupplements, other listed drugs).
- Follow linked step therapy documents to ensure required prior trials are met.
HCPCS/J/Q-linked prior auth risk — include the listed code and follow PA/step therapy rules
Coverage for many ophthalmic VEGF inhibitors is tied to HCPCS/J/Q codes and subject to step therapy and prior authorization risks associated with those codes; include the specified code on authorization and claims submissions.
Denial risk from unmet criteria — follow linked medical necessity and step therapy documents
Failure to follow the referenced step therapy or medical necessity criteria (which are hosted in separate linked documents) can change coverage/access and may trigger noncoverage or denial; providers must adhere to the linked criteria and submission requirements.
- The policy repeatedly references external criteria and fax forms — those documents contain the clinical conditions and documentation needed for approval.
- Providers should review the linked criteria before submitting a PA or step therapy exception request.
Key Terms and Routing
Initial Therapy / First-Line Requirements
Initial therapy requirements (class-level)
Preferred products required prior to non-preferred for certain classes
See per‑drug links for exact prior authorization or step therapy criteria
Initial therapy step requirement
Step therapy prerequisite
Documentation of trials is required per linked step therapy criteria.
Initial therapy rules (referenced)
Initial coverage requires meeting step therapy and/or medical necessity criteria where indicated.
See Aetna step therapy and product‑specific criteria documents linked in the policy.
Step Therapy Tables and Requirements
| Requirement | Details |
|---|---|
| Must try preferred drug(s) first | |
| Step therapy requires trial of listed preferred products before approval of a non-preferred product; an exception process exists for specific clinical reasons |
| Scope | Policy note |
|---|---|
| Multiple categories and products (e.g., erythropoiesis stimulating agents, IVIG) are marked 'Indications subject to step therapy' | |
| Product entries reference 'Link to criteria' or 'Step therapy criteria' for specific prior trials and sequencing; see linked criteria for details |
| Drug / category | Step therapy rule |
|---|---|
| Rituximab (including originator and biosimilars) | |
| Step therapy applies to all requests except rheumatoid arthritis; preferred biosimilars Ruxience and Truxima are listed as preferred (step therapy links and fax forms provided for other products) |
| Class / examples | Step therapy requirement |
|---|---|
| Ophthalmic VEGF inhibitors (examples: Bevacizumab/Avastin, Byooviz, Eylea, Pavblu, Beovu, Cimerli, Lucentis) | |
| Preferred products from both tiers must be tried and documented prior to approval of a non-preferred ophthalmic VEGF inhibitor; product-specific step therapy criteria and fax forms are referenced |
| Applicability | Requirement |
|---|---|
| Ophthalmic VEGF inhibitors and selected viscosupplements (general rule referenced across entries) | |
| A preferred product from both tiers is required prior to receiving a non-preferred product; documentation and product-specific criteria links are provided for required trials |
| General rule | Action for providers |
|---|---|
| Where a product or indication is labeled 'subject to step therapy', the step therapy sequence must be followed | |
| Follow the product-specific step therapy criteria linked in the policy (use the linked medical necessity criteria and fax request form where indicated) to document required trials/ failures |
Site of Care / Administration Notes
Infusion-center or office administration — check local billing/site rules
Site-of-care specifics are not provided in this section; many agents listed are administered in infusion centers or office settings when billed under Part B.
- Confirm site-of-care billing rules with the applicable plan or facility as they are not detailed here.
Biosimilar Groupings and Links
Avastin (bevacizumab) biosimilars — reference criteria/fax form
Avastin and its biosimilars (e.g., Mvasi Q5107) are listed with links to criteria and fax forms; providers should reference those links when requesting coverage.
Avastin grouping — HCPCS Q5118 and criteria links
Avastin is listed with HCPCS Q5118 and a link to criteria; biosimilars and the originator are grouped under the Avastin category — use the product line links for PA/documentation requirements.
Bevacizumab (Avastin) — preferred with HCPCS Q5107; see criteria/fax form
Bevacizumab (reference biologic Avastin) and its biosimilars are listed as preferred with HCPCS Q5107 and include links to criteria and fax forms for PA/submission.
- Use the listed HCPCS/Q codes and the linked fax form when a PA or documentation submission is required.
Bevacizumab biosimilar listing (Q5118) — follow linked forms/criteria
Bevacizumab entries include HCPCS Q5118 and reference to criteria and fax forms — follow those links for PA and documentation guidance.
- Providers should use the product-specific links for prior authorization submission when indicated.
Trastuzumab (Herceptin) and biosimilars — reference HCPCS/Q-codes and criteria
Trastuzumab (Herceptin) and multiple biosimilars are listed with HCPCS/Q-codes and links to medical necessity criteria and fax forms; include those references when submitting requests.
Remicade group — Inflectra (Q5103) listed with criteria links
Inflectra (Q5103) is listed under Remicade/infliximab groupings with links to medical necessity criteria and fax forms; follow the listed criteria for PA and step therapy where applicable.
- Inflectra, Renflexis, Avsola and Remicade entries include links to criteria and fax forms for submissions.
Avsola (Q5121) — infliximab listing with criteria/fax form
Avsola (Q5121) is listed with links to medical necessity criteria and a fax request form in the infliximab section; use those links for authorization and documentation.
- Avsola appears in preferred/unpreferred groupings; check the product line for step therapy and PA instructions.
Remicade/infliximab — Q5121 appears in non-preferred/biosimilar groupings; follow criteria
Remicade/infliximab entries include HCPCS Q5121 among non-preferred or biosimilar groupings and reference linked medical necessity criteria — submit PA per those links.
- Providers should reference the HCPCS/J/Q code listed and the linked criteria/fax form when requesting coverage.
Remicade/infliximab — Q5103 listed; use linked criteria/fax form
Remicade/infliximab is also listed with HCPCS Q5103 in non-preferred/biosimilar groupings; linked medical necessity criteria and fax forms apply for PA and step therapy.
- Inflectra (Q5103) and related entries include links to criteria and fax request forms — use them for submissions and documentation.
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