Preferred drug list for Aetna Medicare Advantage with drug coverage plans (PDF)
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Aetna Medicare Advantage plans that offer Part B drug coverage: lists drug categories, preferred and non-preferred medically administered (Part B) drugs, associated HCPCS/J-codes, and notes on step therapy, medical necessity, and prior authorization requirements. This is part 1 of 3 and contains multiple categories and drugs with their codes and brief coverage/PA notes or links to criteria.
No material clinical/coverage changes — has_material_change = false
Coverage Summary
Complement inhibitors (examples: treatments for paroxysmal nocturnal hemoglobinuria [PNH], atypical hemolytic uremic syndrome [aHUS], and other complement‑mediated disorders) are included in this Part B list and may have specific prior authorization and exception requirements. For these agents, the policy requires documentation of diagnosis, relevant laboratory and clinical response data, and prior use or intolerance of preferred agents when step therapy is applicable. For specific coverage details and required supporting documentation, use the medical necessity and step therapy criteria links in each drug entry and submit via the indicated fax form.
Prior authorization exceptions: An exception to step therapy or preferred‑product requirements may be granted when the prescriber documents that the preferred product is contraindicated, not tolerated, or expected to be clinically ineffective for the individual patient. The exception request must reference the patient diagnosis, relevant prior therapies and outcomes, and any supporting clinical rationale. Exception requests are processed per the medical necessity criteria for the specific drug / indication; use the fax request form linked on the drug entry. When PA is not required for a given HCPCS code, that is noted in the drug entry.
General step therapy / preferred drug logic
General step therapy and preferred‑product logic applied across the document:
ALL of the following
- A preferred product must be tried first when step therapy is listed for the indication (preferred‑product‑first).
- Documentation must show an adequate trial of the preferred product (duration and dosing per the linked step therapy criteria) unless a documented contraindication or intolerance exists.
- If the preferred product is ineffective or not tolerated, the prescriber may request coverage of a non‑preferred product by submitting clinical documentation per the linked medical necessity criteria and the fax request form.
- Some categories require sequential trials across tiers (e.g., both tier‑1 and tier‑2 preferred products) before non‑preferred products will be considered; these tier rules are called out in the specific category entries.
- When PA is explicitly not required for a specific HCPCS code, that will be indicated in the drug entry; however, other administrative documentation (e.g., chart notes) may still be necessary for clinical review.
General coverage model reflected in document
General coverage and administrative routing model used for every drug or category entry in this Part B list:
ALL of the following
- Medical necessity criteria link: The specific clinical criteria that must be met for approval are linked from the entry; these define diagnosis, prior therapy, laboratory, and monitoring requirements.
- Step therapy: If step therapy applies for the listed indication, the entry states this and links to the step therapy decision logic; includes required trial duration/dosing thresholds as defined in the step therapy criteria.
- Prior authorization (PA) notes: Entries will indicate whether PA is required or not required for the HCPCS code; when PA is required, instructions and fax form links are provided.
- Fax request form: Each entry provides the fax request form or link used to submit clinical documentation for initial or continuation requests and for exception requests.
- Tiering and sequencing: When products are tiered, the entry identifies preferred first‑line products, second‑tier preferred alternatives (and required sequencing), and non‑preferred products that require prior trial/failure of preferred options.
- Exception process: The pathway to request an exception to step therapy or preferred‑product requirements is specified (refer to medical necessity criteria and fax form); required documentation for exceptions is described in the criteria link.
- Complement inhibitors and other specialty categories: For high‑complexity classes (e.g., complement inhibitors for PNH or aHUS), entries explicitly call out diagnosis‑specific requirements, required laboratory parameters, and ongoing monitoring documentation needed for continuation approvals.
Initial Therapy Criteria (step therapy / preferred product tiers)
Alpha-1 proteinase inhibitors
Alpha-1 antitrypsin deficiency is subject to step therapy; preferred products must be used before non-preferred products.
Document lists preferred and non-preferred alpha-1 products and specifically notes Glassia J0256
Bone resorption inhibitors (osteoporosis and other indications)
Osteoporosis indications are subject to the bone-resorption step therapy structure: first-tier preferred agents (e.g., Zoledronic acid) may be required prior to moving to second-tier preferred or non-preferred products. Many entries include HCPCS codes and links to medical necessity/step therapy criteria and fax forms.
Zoledronic acid entry shows HCPCS J3489 and PA not required
Document lists multiple HCPCS/Q-codes with links to criteria and fax forms
Bone resorption inhibitors (hypercalcemia of malignancy and other indications)
For hypercalcemia of malignancy and prevention of skeletal events, initial therapy with pamidronate or zoledronic acid is expected; second-tier preferred denosumab-type agents and other products require prior trial/failure of first-line agents and link to criteria/forms.
Pamidronate and Zoledronic acid entries indicate no PA and no step therapy
Document enumerates these second-tier products and references links to criteria/forms
Botulinum toxins
Botulinum toxin indications such as blepharospasm and cervical dystonia are subject to step therapy; certain products are preferred and do not require prior authorization while others are non-preferred and link to criteria/forms.
VEGF inhibitors (ophthalmic) - intravitreal/related agents
Ophthalmic VEGF inhibitors are organized in tiers; a preferred product from each tier (including bevacizumab mappings and biosimilars/approved ophthalmic agents) is expected before covering non-preferred ophthalmic VEGF agents. Entries list HCPCS/Q/J codes and link to medical necessity/step therapy criteria and fax forms.
Category header explicitly states tiered preferred product requirement
Document lists 1st tier preferred agents with codes and PA notes
Multiple non-preferred ophthalmic agents are enumerated with codes and links
Continuation Therapy Criteria
General step therapy / preferred drug logic
Many categories and indications in this list are subject to step therapy; continuation/ongoing-treatment rules require documentation of trials/failures per linked criteria and specify where to find those links.
Document repeatedly instructs providers to follow linked criteria and to document trials/failures
These categories and indications are specifically identified in the document as subject to step therapy
Numerous entries show 'Link to criteria' and 'Link to fax form' fields
Exceptions / Exclusions / Routing
Some subcutaneous (SC) products and other entries are routed to Medicare Part D rather than Part B; for example, Hadlima, Rinvoq, Skyrizi SC, Stelara SC, Pyzchiva SC, Yesintek SC, Tremfya SC and other SC agents list 'HCPCS code = Not applicable' and instruct 'See Part D benefit' or 'Request through Part D'. Several entries explicitly say 'Request through Part D' or 'See Part D benefit' (providers should submit requests through Part D processes when indicated).
Applicable Codes
| J0256 | Glassia (alpha-1 proteinase inhibitor) - listed as non-preferred |
| J0257 | Listed in alpha-1 section (appearance in document) |
| J3489 | Zoledronic acid |
| Q5136 | Jubbonti / multiple product category code used repeatedly (category Q-code) |
| J0897 | Prolia / Xgeva (denosumab) - appears for multiple denosumab products |
| J3111 | Evenity |
| Q5158 | Conexxence / Bomyntra / denosumab-bnht - Q-code |
| Q5159 | Ospomyv / Xbryk - Q-code |
| Q5157 | Stoboclo / Osenvelt - Q-code |
| Q5162 | Bildyos / Bilprevda - Q-code |
| J9155 | Firmagon |
| J9264 | Abraxane / paclitaxel (protein-bound) |
| Q5124 | Byooviz |
| J0178 | Eylea |
| J0177 | Eylea HD |
| Q5147 | Pavblu |
| Q5149 | Enzeevu |
| J2778 | Lucentis |
| J2779 | Susvimo |
| J2777 | Vabysmo |
| J0179 | Beovu |
| Q5128 | Cimerli |
| J7318 | Durolane |
| J7325 | Synvisc-one |
| J7326 | Gel-one |
| J7327 | Monovisc |
| J7322 | Hymovis One |
| J7323 | Euflexxa |
| J7328 | Gelsyn-3 |
| J7320 | GenVisc |
| J7321 | Hyalgan / Supartz FX / Visco-3 |
| J7324 | Orthovisc |
| J0717 | Tyruko / Cimzia mapping |
| J2323 | Tysabri |
| J3262 | Actemra |
| Q5156 | Avtozma |
| Q5133 | Tofidence |
| Q5119 | Ruxience |
| Q5115 | Truxima |
| Q5123 | Riabni |
| J9312 | Rituxan |
| J1602 | Simponi Aria |
| J1306 | Leqvio |
| J3032 | Vyepti |
Provider Actions
Step therapy required for listed indications
Step therapy is required for certain indications listed in this policy. Providers must first use the listed preferred products for the specified medical indications (for example, preferred alpha‑1 proteinase inhibitors for alpha‑1 antitrypsin deficiency and specified preferred bone resorption inhibitors for osteoporosis and other listed indications). If the preferred product is ineffective or not tolerated, a non‑preferred product may be considered per the exception process. Follow the linked step therapy criteria for the specific indication when requesting coverage for non‑preferred products.
- Use preferred products first for indications that list step therapy (see individual drug entries and linked step therapy criteria).
- Exceptions are available when clinically appropriate; follow the exception process in the criteria links.
Prior authorization not required for many listed products
Prior authorization is not required for many listed Part B drugs. Providers may bill directly without requesting prior authorization for these products.
Follow linked medical necessity and fax request forms
Follow the Aetna medical necessity and step therapy criteria and use the specified fax request forms when requesting authorization or submitting clinical documentation. Linked criteria and fax forms provide the requirements that must be met for approval.
- Use the medical necessity and step therapy criteria links for specific drugs (e.g., bone resorption inhibitors, botulinum toxins, alpha‑1 proteinase inhibitors).
- Use the linked fax request forms when a form is indicated for submitting documentation for authorization.
Billing rules — use specified HCPCS/Q/J codes when billing
When billing, use the correct HCPCS/Q/J codes listed for each product. Correct coding ensures claims are routed appropriately between Medicare Part B and Part D and supports accurate processing of coverage determinations.
- Bill with the HCPCS/Q/J codes shown in the policy for each product (examples: J3489, J2430, J0256, J0257, J0897, Q5136, J0585, J0588, J0586, J0587, J0589, J3111, Q5158, Q5159, Q5157, Q5161, Q5162, J3590/C9399 for miscellaneous).
- Using the specified HCPCS/J/Q codes directs claims to Part B vs Part D as appropriate.
Route certain SC products via Part D when indicated
Certain subcutaneous (SC) agents may be routed through Part D processes even though they are included in this document. When the policy or codes indicate Part D routing for specific SC products, follow Part D billing and coverage processes accordingly.
- If an SC product is designated to route via Part D in the policy or by coding, submit claims and prior authorization requests through Part D processes per payer instructions.
- Confirm routing when using miscellaneous codes (e.g., J3590/C9399) or product‑specific guidance that indicates Part D handling.
Background
This preferred drug list (Part 1 of 3) identifies Aetna MAPD Part B preferred and non-preferred medically administered drugs, shows HCPCS/J/Q codes, and indicates when step therapy or prior authorization applies. Where listed, entries link to separate medical necessity and step therapy criteria and to fax request forms — providers must follow those linked criteria/forms when seeking coverage or exceptions.
Preferred product: A drug the plan prefers and typically requires to be tried first under step therapy before covering non-preferred alternatives (see general step therapy guidance).
Prior authorization is not required: The plan note indicating that a separate prior authorization is not needed for that product under the stated conditions (examples appear throughout the list).
HCPCS: Healthcare Common Procedure Coding System codes used for billing medical benefit drugs and services.
J/Q codes: J-codes and Q-codes used to bill specific injectable drugs and biologics under the medical benefit.
Part D benefit: Prescription drug benefit administered under Medicare Part D; items routed through Part D are not covered under the Part B medical benefit in this list.
HCPCS/J-code: Code used for billing certain injectable/infused drugs under the medical benefit.
Clinical Evidence
This document does not contain discrete trial metrics or clinical evidence tables within Part 1. For clinical justification, step therapy and coverage decisions the policy directs providers to the externally linked medical necessity and step therapy criteria (see the product-level notes that say 'Link to criteria', 'See step therapy criteria', or provide a link to a criteria PDF) and to the specified fax request forms.
Revision History
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