General step therapy / preference statement
The listed preferred products should be used first. An exception process is available for members who meet specific clinical criteria or have contraindications to preferred products.
ALL of the following
Try preferred products first for the indicated drug class when medically appropriate; coverage for non-preferred products is contingent on prior trial and failure of preferred products or an approved exception.
An exception (prior authorization) process exists when a member has contraindications, intolerance, or clinical rationale for a non-preferred product; see Aetna clinical policy bulletins and the fax request form links for submission instructions.
Provider must document rationale and prior therapy where applicable.
Alpha-1 proteinase inhibitors (initial therapy)
Alpha-1 proteinase inhibitors — Indications subject to step therapy: Alpha-1 antitrypsin deficiency. Preferred products and HCPCS codes listed below should be used first.
ALL of the following
Indication: Alpha-1 antitrypsin deficiency.
Preferred products
Prolastin-C (HCPCS J0256); follow Aetna medical necessity criteria and fax request form link.
Zemaira (HCPCS J0256); follow Aetna medical necessity criteria and fax request form link.
Aralast NP (HCPCS J0256); follow Aetna medical necessity criteria and fax request form link.
Glassia (HCPCS J0257); follow Aetna medical necessity criteria and fax request form link.
Step therapy: Preferred products should be tried prior to coverage of non-preferred alpha-1 products unless an exception is approved.
Bone resorption inhibitors (initial therapy)
Bone resorption inhibitors — Indication subject to step therapy: Osteoporosis. Both preferred products are required prior to receiving the non-preferred product Evenity.
ALL of the following
Indication: Osteoporosis.
Preferred products (try both preferred tiers before non-preferred)
Prolia (HCPCS J0897) — medical necessity criteria; prior authorization: none required for Prolia per policy link.
Zoledronic acid (HCPCS J3489) — prior authorization is not required; try when clinically appropriate.
Non-preferred product: Evenity (HCPCS J3111) — coverage requires trial and failure of both preferred products above or an approved exception; follow Evenity criteria and fax request form for submission.
Botulinum toxins (initial therapy)
Botulinum toxins — Indications listed below. Preferred agents (Botox, Xeomin) have no step therapy requirement; other agents may require adherence to product-specific criteria.
ALL of the following
Indications: Blepharospasm; Cervical dystonia; Chronic sialorrhea; Upper limb spasticity; and other indications as listed.
Preferred products
Botox (HCPCS J0585) — follow medical necessity criteria; step therapy: none.
Xeomin (HCPCS J0588) — follow medical necessity criteria; step therapy: none.
Other products (Daxxify J0589, Dysport J0586, Myobloc J0587) — follow product-specific medical necessity and step therapy criteria where applicable; use preferred products first when clinically appropriate.
Complement inhibitors (initial therapy)
Complement inhibitors — Indications include hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, neuromyelitis optica spectrum disorder, myasthenia gravis, and others. Preferred products (Soliris, Ultomiris) are listed; follow indication-specific criteria for therapy selection.
ALL of the following
Indications include: Hemolytic uremic syndrome; Paroxysmal nocturnal hemoglobinuria; Neuromyelitis optica spectrum disorder; Myasthenia gravis; and others.
Preferred products
Soliris (HCPCS J1299) — follow indication-specific medical necessity criteria; step therapy: none for listed indications unless specified in clinical criteria.
Ultomiris (HCPCS J1303) — follow indication-specific medical necessity criteria; step therapy: none for listed indications unless specified in clinical criteria.
Other complement-targeted agents (e.g., Vyvgart J9332/J9334, Rystiggo J9333) — follow product-specific medical necessity and step therapy criteria; use preferred agents when clinically appropriate and per indication-specific rules.
Colony stimulating factors (short-acting and long-acting) (initial therapy)
Colony stimulating factors (short-acting and long-acting) — preferred biosimilars are listed and some products do not require prior authorization when billed under Part B.
ALL of the following
Indications: neutropenia and other oncology/supportive care indications per medical necessity criteria.
Preferred biosimilars / products
Preferred short-acting and long-acting CSFs (use biosimilars when available per formulary guidance).
Where specified, certain agents billed under Part B do not require prior authorization — follow the product-specific notes in the policy (e.g., select formulations of zoledronic acid and specified CSFs).
Prior authorization: follow the policy’s product-level notes; if a product is noted as prior-auth not required under Part B, submit accordingly; otherwise, obtain prior authorization with documentation of indication and prior therapies as required.
Erythropoiesis stimulating agents (ESAs) (initial therapy)
Erythropoiesis stimulating agents (ESAs) — follow initial therapy and medical necessity mapping per product-specific criteria.
ALL of the following
Indications: anemia associated with chronic kidney disease, chemotherapy-induced anemia, and other labeled indications per medical necessity criteria.
Initial therapy/step therapy mapping: use preferred ESA products and biosimilars when available and follow Aetna medical necessity criteria for dosing, monitoring, and documentation prior to coverage of alternative agents.
Prior authorization: obtain prior authorization when required by product-level rules; document hemoglobin levels, treatment intent, and previous therapies as specified in the clinical policy.
IVIG and SCIG (initial therapy / coverage linkage)
IVIG (intravenous immunoglobulin) and SCIG — General coverage linkage and requirements apply: follow indication-specific medical necessity criteria and Aetna clinical policy bulletins for step therapy, quantity limits, and documentation requirements.
ALL of the following
Indications: refer to Aetna clinical policy for covered indications for IVIG and SCIG (e.g., primary immunodeficiency, certain neurologic and hematologic disorders).
Coverage linkage: IVIG/SCIG coverage is governed by Aetna medical necessity criteria; prior authorization is typically required and medical records must document diagnosis, severity, prior therapies, and objective measures where applicable.
Step therapy/initial therapy: when multiple immunoglobulin products are available, preferred products should be used first where the policy specifies; exceptions may be granted for product-specific intolerance or clinical rationale.
Billing note: ensure appropriate HCPCS codes and units are submitted; follow dose- and indication-based quantity limits in the clinical policy.
VEGF inhibitors (ophthalmic) (initial therapy / tiering)
VEGF inhibitors (ophthalmic) — Tiering and prior requirement: preferred products should be used first; follow PA rules where specified.
ALL of the following
Indications: ophthalmic neovascular disorders (e.g., wet AMD, diabetic macular edema, retinal vein occlusion) per medical necessity criteria.
Tiering: preferred ophthalmic VEGF inhibitors should be tried before non-preferred agents when the formulary indicates preference; use product-level links and criteria to determine preferred agents for the indication.
Prior authorization: obtain prior authorization for non-preferred ophthalmic VEGF inhibitors when required; document prior trial/failure or clinical rationale for exception.
Viscosupplements (initial therapy / prior auth)
Viscosupplements (single- and multiple-injection formulations) — Prior authorization status varies by product; follow product-level notes in policy.
ALL of the following
Indications: symptomatic osteoarthritis of the knee when medically appropriate and per policy criteria.
Prior authorization: some viscosupplement products require prior authorization while others do not; check the product-specific policy entries for prior authorization requirements before billing.
Initial therapy: use preferred viscosupplement formulations per formulary where specified; document prior conservative therapy (e.g., physical therapy, NSAIDs) as required by medical necessity rules.