Medicare Part B preferred drug list — Aetna Medicare Advantage (MA) only plans
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Lists preferred and non-preferred medically administered Part B drugs by therapeutic category for Aetna Medicare Advantage plans and describes that some drugs are subject to step therapy, prior authorization, or other limits. Affects providers ordering/administering Medicare Part B drugs for Aetna MA members.
No material clinical or coverage changes in this revision.
Coverage Criteria and General Policy Rules
General Step Therapy/Preferred Product Requirement
Covered when meeting step therapy and medical necessity criteria as specified for each drug/indication
Exception process available
Prior Authorization Not Required (examples)
Certain preferred drugs are designated as not requiring prior authorization
Coverage contingent on medical necessity and step therapy links
Products covered when meeting referenced medical necessity and step therapy criteria
Specific product-level links to criteria or 'Prior authorization not required' flags are included in the product entries.
Prior authorization not required entries
Exceptions noted
Verify that clinical indication and billing align with the entry
Product-level coverage references
Covered when following product-specific criteria (as referenced); many entries require meeting linked medical necessity criteria and may be subject to step therapy
This section lists many agents each with an associated 'Link to criteria', 'Step therapy criteria' or indicates 'None' if not applicable
General coverage conditioned on linked criteria
Covered when administrative and clinical criteria (linked) are met; many entries require prior authorization or step therapy documentation.
See linked criteria per drug/category for exact requirements
General coverage linkage to medical necessity and step therapy criteria
Covered when medical necessity criteria or step therapy criteria (as linked) are met for each listed drug or category.
Specific step therapy sequences and required prior trials are detailed in the referenced step therapy criteria documents.
Preferred product and step therapy logic: the policy requires trial of listed preferred product(s) in a drug class before a non-preferred Part B product will be covered. An exception process is available for specific cases that may warrant a non-preferred product; providers should consult the referenced step therapy criteria documents for indication-specific rules and the exception pathway details.
Within the extracted portions there are no formal, drug-level exclusion statements; non-preferred drugs are presented as grouped listings but this segment does not explicitly list products as excluded. Coverage determinations for non-preferred agents are governed by the linked medical necessity and step therapy criteria referenced in each product entry.
Intravenous iron and other IV products: some IV iron products in the listing are identified as non-preferred and reference separate medical necessity/step therapy criteria. Providers should follow those referenced criteria for IV iron coverage decisions; when an IV iron is non-preferred, the linked criteria will indicate prior authorization or step therapy requirements.
Examples of drugs that do not require prior authorization in these excerpts include Halaven (HCPCS J9179) and select chemotherapy or supportive agents listed as 'not required' for prior authorization. Also, the docetaxel and paclitaxel entries show differing PA expectations in this segment (see product rows for exact PA language). Always verify the per-drug entry for the explicit 'Prior authorization is not required' flag.
Formulary and plan features may change over time. For a complete description of plan benefits, exclusions, limitations, and conditions of coverage, refer to the plan Evidence of Coverage; product availability and preferred designations are subject to change.
This extract does not contain explicit 'not medically necessary' declarations for individual drugs. However, when required step therapy or referenced medical necessity criteria are not met, coverage may not be approved — the policy relies on the linked medical necessity criteria to define when a request is medically necessary.
Many product entries in this document refer to separate medical necessity criteria documents or step therapy links rather than embedding full not-medically-necessary language. Where those linked medical necessity criteria apply, they govern whether an item meets coverage conditions; this extract does not itself state explicit 'not medically necessary' rulings.
Docetaxel and paclitaxel PA notes in this segment are presented at the product-row level: the docetaxel row contains an incomplete PA statement in the excerpt while paclitaxel is shown as prior authorization not required in this portion. Providers must check the referenced product entry and linked criteria/fax form to confirm the current PA requirement.
Requests that do not include required documentation — such as completion of specified step therapy trials or submission of the referenced medical necessity criteria and fax request form — may not meet coverage requirements and therefore may be denied. Providers should submit the linked criteria/fax form information when requesting authorization for non-preferred or step therapy–subject drugs.
HCPCS/Q-code mappings and Code Lists
| Q5115 | Listed repeatedly as group/column identifier for entries in this segment |
| Q5103 | HCPCS code mapping for Inflectra (Remicade biosimilar) |
| Q5104 | HCPCS code mapping for Renflexis (Remicade biosimilar) |
| J1602 | HCPCS code mapping for Simponi Aria |
| Q5121 | HCPCS code mapping for Avsola |
| J1745 | HCPCS code mapping for Remicade / Unbranded infliximab in some entries |
| J0717 | HCPCS code mapping for Cimzia |
| J9294 | octreotide acetate depot (referenced grouping) |
| J9296 | octreotide acetate depot (referenced grouping) |
| J9297 | octreotide acetate depot (referenced grouping) |
| J9314 | octreotide acetate depot (referenced grouping) |
| J2353 | mapped code for octreotide depot / Sandostatin LAR reference |
| J2502 | Signifor LAR reference |
| J0490 | Benlysta (belimumab) reference |
| J0491 | Saphnelo (anifrolumab) reference |
What Providers Must Do (Prior Auth, Step Therapy, Fax Forms)
Confirm whether prior authorization is required for each product
Prior authorization (PA) requirements differ by drug: some listed Part B drugs are explicitly noted as “Prior authorization is not required” (examples: Zoledronic acid J3489; Zarxio Q5101), while many other products reference linked medical necessity criteria or fax request forms that govern PA. Providers must check the specific product entry and its linked criteria/fax form to determine whether PA is required for that HCPCS/Q-code.
- Zoledronic acid (J3489) — “Prior authorization is not required” and “Step therapy criteria = None” (see product entry).
- Zarxio (Q5101) — listed as a preferred colony stimulating factor with “Prior authorization is not required.”
- Many biosimilars and other HCPCS-coded agents include “Link to criteria” and “Link to fax form” indicating PA/medical necessity review is required per the linked documents.
Note products explicitly labeled 'PA not required' (e.g., Eligard J9217)
Some individual products are specifically flagged as not requiring prior authorization (example: Eligard J9217). For other listed agents the product entry shows a link to medical necessity criteria — follow that entry to determine PA status.
- Eligard (J9217) — “Prior authorization is not required” noted in the Eligard product entry.
- When an entry lists “Link to criteria” or a fax form, submit per those instructions if PA is required.
Check linked medical necessity criteria/fax forms for biosimilars and HCPCS-coded agents
PA requirements vary across biosimilars and HCPCS-coded agents; many Remicade/biosimilar entries (Inflectra Q5103, Renflexis Q5104, Avsola Q5121, Remicade J1745) include links to medical necessity criteria and fax request forms — providers must follow those links for authorization instructions.
Examples of agents listed as 'PA not required' — verify entry-level guidance
The policy lists several examples where prior authorization is not required (e.g., bortezomib/Velcade J9046/J9048/J9049; Alimta J9305 in some entries). When PA status is not explicit, consult the product-level link to criteria or fax form before billing/administration.
Consult linked criteria and fax forms for HCPCS-coded PA requirements
For HCPCS-coded drugs the policy frequently points to a linked medical necessity criteria page and a fax request form; providers must consult those linked documents to determine and submit any required prior authorization.
- Many oncology, biosimilar and ophthalmic HCPCS entries include “Link to criteria” and “Link to fax form” — use those links when submitting PA requests.
- If an HCPCS entry does not explicitly state “Prior authorization is not required,” assume PA may be required and follow the linked criteria/fax process.
Follow step therapy: try preferred product(s) first
Where step therapy applies, providers must use preferred products first; coverage of non-preferred products generally requires documentation of trial/failure of preferred agents or an approved exception.
- The policy states: “The listed preferred products should be used first... An exception process is in place for specific cases that may call for a non-preferred product.”
- Step therapy criteria and the required trial/failure sequence are provided in linked step therapy criteria documents for each drug/indication.
Verify whether the specific indication is subject to step therapy
Step therapy is applied to multiple listed indications and drug classes (examples include Hemophilia A prophylaxis and immunologic indications under J9155); check the product entry for whether the indication is “subject to step therapy.”
- Hemophilia A (prophylaxis) — factor VIII entries are labeled “Indications subject to step therapy.”
- Immunologics (J9155) — ulcerative colitis and Crohn’s disease entries show preferred products and note step therapy applicability.
Follow product-level step therapy flags and linked criteria
Numerous product entries across categories are explicitly labeled “subject to step therapy” or “Indications subject to step therapy” and include links to step therapy criteria; providers must follow the linked step therapy pathways where indicated.
- Remicade and biosimilars entries (Inflectra, Renflexis, Avsola) include step therapy flags or links to step therapy criteria.
- Ophthalmic VEGF inhibitors and oncology biosimilars similarly reference step therapy criteria via links in their entries.
Interpret 'Step therapy criteria = None' vs linked step therapy criteria
Many entries explicitly state “Indications subject to step therapy” and reference step therapy criteria or linked documents — when an entry provides “Step therapy criteria = None” that indicates no step requirement for that product/indication.
Adhere to step therapy sequences defined in linked criteria
Multiple drugs and categories are marked “Indications subject to step therapy” and the policy points providers to linked step therapy criteria that define required prior trials and failure definitions required for coverage of non-preferred agents.
- Bevacizumab (Avastin) ophthalmic use is noted with specific PA/step therapy language — see the Avastin entry.
- For specific sequences (for example trial of bevacizumab before second-tier agents), follow the referenced step therapy criteria documents.
Use the linked medical necessity criteria and fax forms for PA submissions
Providers must use the document’s referenced medical necessity criteria pages and fax request forms when submitting prior authorization requests; many product entries include explicit “Link to criteria” and “Link to fax form” instructions.
- Entyvio (J3380), Inflectra (Q5103) and many others list “Prior authorization is not required” OR “Medical necessity criteria = Link to criteria” — follow the listed link or fax form per the entry.
- When an entry includes a fax request form link, submit that fax form with the medical necessity documentation for authorization decisions.
Submit required medical necessity criteria and fax request forms listed in product entries
Several product lines (examples: Kovaltry J7211, Nuwiq J7209, Entyvio J3380, Inflectra Q5103) include links to medical necessity criteria and fax request forms — send the specified documents as part of the authorization request.
- Kovaltry and Nuwiq (Hemophilia A) — “Medical necessity criteria = Link to criteria” and “Fax request form = Link to fax form.”
- Entyvio and Inflectra (IBD/immunologic indications) — entries reference criteria links and fax forms for PA processing.
Provide the referenced criteria and fax form with authorization requests
Many agents explicitly reference “Link to criteria” and “Link to fax form”; the policy requires submission of the referenced medical necessity criteria and the fax request form when requesting authorization for non-preferred or step therapy-subject drugs.
- Remicade/biosimilar and oncology biosimilar entries often include both a criteria link and a fax request form — include both as instructed.
- If an entry indicates “Prior authorization is not required,” no fax form is required; otherwise submit per the entry’s fax instruction.
Required submission of product-specific criteria and fax form
Multiple product entries indicate the provider must submit the specified medical necessity criteria and the associated fax request form when requesting coverage for non-preferred or step therapy-subject drugs; failure to provide those documents may prevent authorization.
- For oncology biosimilars and many biologics the entry shows “Link to criteria” plus “Fax request form = Fax request form” — include both in PA submission.
- When an entry lists “Step therapy criteria = Link to criteria,” documentation showing trial/failure of preferred agent(s) should accompany the fax form.
Follow product entries’ required documentation and fax forms
Entries across the policy reference medical necessity criteria and specific fax request forms for many drugs; providers must follow those referenced documents and submit required fax forms when applicable to support authorization decisions.
- Ophthalmic VEGF, viscosupplement and other category entries include explicit fax form links — follow them for PA or coverage support.
- If an individual product entry states “not required,” the linked fax form is not necessary for PA; otherwise include the fax form per the entry.
Risk of denial if step therapy is not completed before using a non-preferred drug
Using a non-preferred Part B drug without completing required step therapy (trial/failure of preferred products) or obtaining an approved exception may result in denial of coverage.
- The policy explains: “The listed preferred products should be used first... An exception process is in place for specific cases that may call for a non-preferred product.”
- If step therapy is required and documentation of prior trial/failure or an approved exception is not provided, coverage for the non-preferred drug may be denied.
PA requirements depend on the specific product entry
Prior authorization requirements are conditional on the product: some entries explicitly state “Prior authorization is not required” (e.g., Eligard J9217) while adjacent or related products may require PA via linked criteria — check each product entry.
IV iron: note which products do or do not require PA
Certain IV iron products are explicitly listed as not requiring prior authorization (sodium ferric gluconate J2916; Infed J1750; Venofer J1756). Other IV iron agents (Feraheme, Injectafer, Monoferric) reference step therapy/criteria links and may require PA.
Denial risk if required criteria or fax form are not provided
Requests that do not include required step therapy documentation, medical necessity criteria, or the specified fax request form (when listed) may be denied; many non-preferred oncology biosimilars and biologics reference criteria/fax requirements for authorization.
- Oncology biosimilars and Avastin-related entries often show “Link to criteria” and “Fax request form = Fax request form” — missing those items increases denial risk.
- Rituxan and other biologics list linked criteria and fax forms; include the referenced documentation to reduce denial risk.
Note Avastin ophthalmic PA note; verify other entries individually
Bevacizumab (Avastin) is explicitly noted as not requiring prior authorization for indicated ophthalmic uses; however, many other drugs and categories reference medical necessity criteria and fax forms — where “not required” is not stated, follow the linked criteria.
- Bevacizumab (Avastin) — “Medical necessity criteria = Prior authorization is not required” for the listed Avastin ophthalmic entry.
- For Avastin biosimilars and other oncology entries, check the product row for links to criteria and fax forms before assuming PA is not required.
Initial Therapy and Step Requirements
Initial step therapy requirement
Preferred products should be used first in classes subject to step therapy
Exception process may allow non-preferred product
Initial therapy — step therapy applies
Step therapy applies for initial therapy in listed indications
See product entries for 'Step therapy criteria = None' or links to criteria.
Initial therapy / step therapy notes
Initial therapy and step therapy notes are provided per product/category.
No explicit step-fail/failover logic present in these chunks; follow linked criteria for details
PD1/PDL1 initial therapy (refer to linked criteria)
PD1/PDL1 agents initial therapy notes (refer to linked criteria for full rules)
Initial therapy notes (examples)
Where specified, initial therapy rules or prior authorization status are indicated per drug.
Step Therapy Tables and Sequences
| Requirement | Summary |
|---|---|
| Trial of preferred product(s) required before covering non-preferred Part B drugs | |
| Preferred products listed for the drug class must be used first; an exception process exists for cases requiring non-preferred products |
| Drugs / Indications | Step therapy note |
|---|---|
| Hemophilia A (prophylaxis) — Kovaltry (J7211), Nuwiq (J7209) listed as preferred; some non-preferred factor VIII products listed | |
| Immunologics for ulcerative colitis / Crohn's — Entyvio (J3380), Inflectra/Renflexis (Q5103/Q5104) noted as preferred; category marked 'Prior authorization is not required' for some entries | |
| Category: Bone resorption inhibitors — Zoledronic acid (J3489) listed with 'Prior authorization is not required'; 2nd-tier preferred/non-preferred sequencing specified |
| Agent / Category | Step therapy linkage |
|---|---|
| Remicade and biosimilars (Inflectra Q5103, Renflexis Q5104, Avsola Q5121, Remicade J1745) — entries indicate 'Step therapy criteria = None' for some biosimilars and links to step therapy/medical necessity criteria for others | |
| Ankylosing spondylitis and other indications — Inflectra/Renflexis listed with links to criteria or 'None' for step therapy where applicable | |
| Avastin and biosimilars (Zirabev Q5118, Avastin J9035, Alymsys Q5126) — step therapy criteria and links to criteria/fax forms are provided per agent |
| Scope | Provider action |
|---|---|
| Many drugs and categories (e.g., SCIG/IVIG, PD1/PDL1 oncology agents, multiple myeloma therapies) are explicitly labeled 'subject to step therapy' | |
| Providers must follow the linked step therapy criteria and submit required fax request forms or documentation when indicated | |
| Failure to complete required step therapy or provide required documentation may result in coverage denial for non-preferred products |
| Drug / Class | Indications subject to step therapy |
|---|---|
| Octreotide acetate depot / Sandostatin LAR / Signifor LAR (J2353, J2502) — listed under systemic indications with links to criteria; 'not required' or links to criteria noted per product | |
| Systemic lupus erythematosus agents (Benlysta J0490, Saphnelo J0491) — entries reference links to criteria and fax forms; step therapy applicability shown | |
| VEGF inhibitors (ophthalmic) and bevacizumab (Avastin C9257/J7999, Byooviz Q5124, Eylea J0178/J0177) — marked 'Indications subject to step therapy' with product-level criteria and fax form links | |
| Viscosupplements (Durolane J7318, Synvisc-one J7325, Gel-one J7326, Monovisc J7327, Hymovis J7322, etc.) — many entries note step therapy or link to criteria and indicate whether prior authorization is required |
Biosimilar Preferences and Notes
Neulasta and related CSF biosimilars — PA/preferred status per listing
For colony stimulating factors and long‑acting CSFs, certain biosimilars are listed as preferred or as not requiring prior authorization where noted; providers should verify PA status per the linked criteria.
Remicade — preferred/non‑preferred & code mappings
Remicade and its biosimilars are presented with HCPCS/Q‑code mappings and varying preferred status; provider billing must use the mapped code and follow linked medical necessity criteria for authorization.
Inflectra (Q5103) — mapped to Remicade biosimilars with criteria links
Inflectra (Q5103) is mapped as a Remicade biosimilar and linked to medical necessity criteria; some Inflectra entries indicate 'Step therapy criteria = None' for preferred indications but providers must follow the linked criteria when present.
Renflexis (Q5104) — mapped to Remicade biosimilars with criteria links
Renflexis (Q5104) is mapped as a Remicade biosimilar and linked to medical necessity criteria; some entries show 'Step therapy criteria = None' for preferred use, but linked criteria/fax forms govern authorization where shown.
Avsola (Q5121) — mapped & linked to criteria/fax form
Avsola (Q5121) is included in the Remicade/biosimilar group and is linked to medical necessity criteria and a fax request form — providers must use those links for authorization submissions.
- Avsola, Q5121 — 'Medical necessity criteria = Link to criteria' and 'Fax request form = Link to fax form' in the Remicade group.
Zirabev (Q5118) — Avastin biosimilar with criteria/step therapy links
Zirabev (Q5118) is listed under the Avastin/biosimilar group with link(s) to medical necessity criteria and step therapy; verify and follow the linked criteria and fax form for authorization.
- Zirabev mapped to Q5118 — 'criteria = Link to criteria' and 'Link to fax form' are included in the Avastin listings.
- Avastin group entries include step therapy criteria and require adherence to linked rules for non‑preferred agents.
Byooviz (Q5124) and other VEGF biosimilars — follow mapped codes & criteria
Referent VEGF inhibitor biosimilars such as Byooviz (Q5124) are listed with HCPCS mappings and links to medical necessity criteria; provider submissions must follow the linked criteria and any stated step therapy.
- Byooviz (Q5124) — 'Medical necessity criteria = Link to criteria' and 'Fax request form = Link to fax form' in the Avastin/VEGF inhibitor listings.
- Preference sequencing and step therapy rules are provided in the linked criteria documents.
Background and Scope
Background: medically administered Medicare Part B drugs listed here span multiple therapeutic classes (for example, alpha-1 proteinase inhibitors, bone resorption inhibitors, botulinum toxins, complement inhibitors, colony stimulating factors, enzyme replacement therapies, immunologics and biologics, IV iron, IVIG/SCIG, MS agents, and oncology biologics). The policy uses step therapy and linked medical necessity criteria to manage preferred versus non-preferred product coverage for Aetna Medicare Advantage members.
Definitions and Key Terms
Policy Revision History
Aetna Medicare Advantage Part B preferred drug list policy document published (document code Y0001_NR_4168512_2025_C 4168504-01-01).
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