CurrentAetnaPolicy N/A

Preferred drug list for Aetna Medicare Advantage with drug coverage plans (PDF)

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.

Policy Summary

PayerAetna

PolicyPreferred drug list for Aetna Medicare Advantage with drug coverage plans (PDF)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must use preferred products listed in a class before a non-preferred product will be covered when step therapy applies; see linked step therapy criteria for details and for specific indications.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — has_material_change = false

30+Drug products listed in part 1

multipleCategories covered (examples)

manyPA not required noted

MultipleCategories with step therapy

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Products/Codes in Part 2

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

HCPCS code(s): Each entry lists the billing HCPCS code(s) (or misc codes such as J3590/C9399 when applicable).
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.

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.

Alpha-1 step therapy: Indication: Alpha-1 antitrypsin deficiency - Preferred drugs: Prolastin-C, Zemaira; Non-preferred examples: Aralast NP, Glassia (HCPCS J0256)

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.

Osteoporosis initial preferred therapy: Indication: Osteoporosis - Zoledronic acid (HCPCS J3489) is listed with 'Prior authorization is not required' and 'Step therapy: None' as a first-line preferred product

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.

Continuation/ongoing-treatment - general: Where indicated, coverage is conditional upon step therapy for specific indications as listed; providers must document trials/failures per the linked step therapy/medical necessity criteria

Document repeatedly instructs providers to follow linked criteria and to document trials/failures

Examples of categories with step therapy noted: Examples: Gonadotropin-releasing hormone agonists (advanced prostate cancer, gender dysphoria, recurrent AR+ salivary gland tumors), Intravenous iron (after intolerance or unsatisfactory response to oral iron), VEGF inhibitors (ophthalmic) require preferred product trials before non-preferred products, PD-1/PD-L1 agents have specific indications subject to step therapy per linked criteria

These categories and indications are specifically identified in the document as subject to step therapy

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

HCPCS / J-codes explicitly listed (examples)mixed

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

1–10 of 50

1/5

Gonadotropin-releasing hormone agonistsHCPCS

J9217	Lupron depot / Eligard mapping (Eligard also referenced as J0881 = J9217 in doc)
J3315	Trelstar
J9202	Zoladex
J0881	Preferred drugs, mapped in doc (Eligard referenced)

Gonadotropin-releasing hormone antagonistsHCPCS

J9155

Firmagon

Immunologics (IV biologics)HCPCS

Q5103	Inflectra
Q5104	Renflexis
Q5121	Avsola
J1745	Remicade
J3380	Entyvio IV
J1628	Tremfya IV
Q9997	Pyzchiva IV

Intravenous iron productsHCPCS

J1750	Infed (iron dextran)
J1756	Venofer
Q0139	Feraheme
Q0138	Feraheme (additional code)
J1439	Injectafer
J1437	Monoferric

IVIG productsHCPCS

J1561	Gammaked / Gamunex-C
J1459	Privigen
J1552	Alyglo
J1554	Asceniv
J1556	Bivigam
J1572	Flebogamma
J1569	Gammagard Liquid
J1553	Yimmugo

SCIG productsHCPCS

J1561	Gammaked / Gamunex-C (SCIG mapping referenced)
J1559	Hizentra
J1558	Xembify
J1551	Cutaquig
J1555	Cuvitru
J1575	HyQvia
J1569	Gammagard Liquid

Multiple sclerosis therapiesHCPCS

J2350	Ocrevus
J2351	Ocrevus Zunovo
J2329	Briumvi
J0202	Lemtrada
J2323	Tysabri

Breast cancer / HER2-targeted agentsHCPCS

J9316	Phesgo
J9306	Perjeta
Q5117	Kanjinti
Q5112	Ontruzant
Q5113	Herzuma
Q5114	Ogivri
Q5116	Trazimera
J9355	Herceptin
J9356	Herceptin Hylecta
Q5146	Hercessi

Rituxan and biosimilarsHCPCS

Q5119	Ruxience
Q5115	Truxima
Q5123	Riabni
J9312	Rituxan
J9311	Rituxan Hycela

Liposarcoma agentsHCPCS

J9179	Halaven
J9352	Yondelis

Multiple myeloma agentsHCPCS

J9046	Bortezomib/Velcade (J9046/J9048/J9049 referenced)
J9054	Boruzu
J9145	Darzalex
J9144	Darzalex Faspro
J9176	Empliciti
J9047	Kyprolis
J9227	Sarclisa

PD-1 / PD-L1 inhibitors (oncology)HCPCS

J9119	Placeholder non-specific PD1/PDL1 group mapping in doc
J9271	Keytruda
J9277	Keytruda Qlex
J9173	Imfinzi
J9299	Opdivo
J9289	Opdivo Qvantig
J9022	Tecentriq
J9024	Tecentriq Hybreza
J9119	Libtayo mapping (doc uses J9119 for Libtayo as well)

Pemetrexed / AlimtaHCPCS

J9305	Alimta
J9294	Pemetrexed (one of multiple codes)
J9296	Pemetrexed
J9297	Pemetrexed
J9314	Pemetrexed

Osteoarthritis injections / corticosteroidsHCPCS

J1010	Methylprednisolone acetate
J3300	Triamcinolone acetonide
J3301	Triamcinolone acetonide (other mapping)
J3304	Zilretta

Somatostatin analoguesHCPCS

J1930	Somatuline depot
J2353	Octreotide acetate depot
J2502	Sandostatin LAR

VEGF inhibitors (ophthalmic) - 1st tier preferredHCPCSCovered

C9257	Bevacizumab (Avastin) - ophthalmic mapping / misc
J7999	Bevacizumab (Avastin) - misc billing code
Q5124	Byooviz
J0178	Eylea
J0177	Eylea HD
Q5147	Pavblu
J3590	Eydenzelt misc code mapping
C9399	Eydenzelt misc code mapping

VEGF inhibitors (ophthalmic) - other productsHCPCS

Q5149	Enzeevu
Q5150	Ahzantive
Q5153	Opuviz
Q5155	Yesafili
J0179	Beovu
Q5128	Cimerli
J2778	Lucentis
J2779	Susvimo
J2777	Vabysmo

Paclitaxel (protein-bound) / AbraxaneHCPCS

J9264

Abraxane / paclitaxel (protein-bound)

Ophthalmology - intravitreal and related agentsHCPCS

Q5124	Byooviz
J0178	Eylea
J0177	Eylea HD
Q5147	Pavblu
Q5149	Enzeevu
J2778	Lucentis
J2779	Susvimo
J2777	Vabysmo
J0179	Beovu
Q5128	Cimerli

1–10 of 14

1/2

Viscosupplements (single-injection)HCPCS

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

1–10 of 13

1/2

Viscosupplements (multiple-injection)HCPCS

J7323	Euflexxa
J7325	Synvisc
J7321	Supartz FX / Visco-3 / Hyalgan
J7322	Hymovis
J7324	Orthovisc

Infliximab and biosimilars; related IV biologicsHCPCS

Q5121	Avsola
Q5103	Inflectra
Q5104	Renflexis
J1745	Remicade / Unbranded infliximab / multiple unbranded products
Q5098	Unbranded infliximab / Imuldosa IV mapping
Q9999	Otulfi IV mapping
Q9998	Selarsdi IV mapping
J3590	Starjemza IV
Q5099	Steqeyma IV
Q5138	Wezlana IV

Other IV/biologic agentsHCPCS

J0717	Tyruko / Cimzia mapping
J2323	Tysabri
J3262	Actemra
Q5156	Avtozma
Q5133	Tofidence
Q5119	Ruxience
Q5115	Truxima
Q5123	Riabni
J9312	Rituxan
J1602	Simponi Aria

1–10 of 13

1/2

PCSK9 inhibitorsHCPCS

J1306

Leqvio

Anti-CGRP and migraine therapiesHCPCS

J3032

Vyepti

Severe asthma and eosinophilic biologicsHCPCS

J2786	Cinqair
J2182	Nucala
J2356	Tezspire

Provider Actions

Step Therapy

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

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.

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

Policy Summary

PayerAetna

PolicyPreferred drug list for Aetna Medicare Advantage with drug coverage plans (PDF)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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.

Zoledronic acid entry shows HCPCS J3489 and PA not required

Second-tier preferred and other agents: 2nd tier preferred drugs after trial/failure of Zoledronic acid include: Jubbonti (Q5136), Prolia (J0897), Evenity (J3111), Conexxence/denosumab-bnht (Q5158) and numerous other denosumab/Q-code products — each entry links to medical necessity, step therapy criteria, and a fax request form

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.

Initial agents: Indications: hypercalcemia of malignancy and prevention of skeletal events — Pamidronate (HCPCS J2430) and Zoledronic acid (HCPCS J3489) are listed as first-line agents with 'Prior authorization is not required' and 'Step therapy: None'

Pamidronate and Zoledronic acid entries indicate no PA and no step therapy

Second-tier after trial/failure: After trial/failure of Pamidronate or Zoledronic acid, 2nd tier preferred drugs include Xgeva (J0897) and multiple Q/J-coded denosumab or related products (Wyost Q5136; Bomyntra/Denosumab-bnht Q5158; Osenvelt Q5157; Xbryk Q5159; Aukelso Q5161; Bilprevda Q5162; others) — entries link to medical necessity/step therapy criteria and fax forms

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.

Preferred botulinum products: Preferred drugs: Botox (HCPCS J0585) and Xeomin (HCPCS J0588) — both entries indicate 'Prior authorization is not required'

Document marks Botox and Xeomin as preferred and PA not required

Non-preferred botulinum products: Non-preferred: Daxxify (J0589), Dysport (J0586; links to criteria and fax form), Myobloc (J0587)

Non-preferred botulinum products are listed; Dysport specifically links to criteria and fax form

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.

Tiered ophthalmic VEGF step therapy: Category: VEGF inhibitors (ophthalmic) — 'Preferred product from both tiers required prior to receiving a non-preferred product'

Category header explicitly states tiered preferred product requirement

First-tier preferred examples: First-tier preferred includes bevacizumab (Avastin) ophthalmic mappings (C9257 / J7999) with 'Prior authorization is not required' and approved biosimilars/agents such as Byooviz (Q5124), Eylea (J0178/J0177), Pavblu (Q5147) — entries include HCPCS and links where applicable

Document lists 1st tier preferred agents with codes and PA notes

Other ophthalmic agents requiring prior trial: Other products listed (Ahzantive Q5150, Enzeevu Q5149, Opuviz Q5153, Yesafili Q5155, Beovu J0179, Cimerli Q5128, Lucentis J2778, Susvimo J2779, Vabysmo J2777, Eydenzelt misc codes) are in other tiers or non-preferred and link to criteria/fax forms; coverage follows the tiered requirement

Multiple non-preferred ophthalmic agents are enumerated with codes and links

Where to find linked criteria:

Each category/drug entry that is subject to step therapy or prior authorization includes links to 'Medical necessity criteria', 'Step therapy criteria', and 'Fax request form' which must be followed for coverage and continuation

Numerous entries show 'Link to criteria' and 'Link to fax form' fields

Examples of HCPCS/J/Q codes that do NOT require prior authorization: J3489, J2430, J2506, Q5101, J0885, J1786, J3385, J0585, J7211, J2782, J2781

Pamidronate (J2430) and zoledronic acid (J3489) are explicitly noted as prior authorization not required for their listed indications.

Documentation Required

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 Rule

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.

Documentation Required

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.