Medicare Part B preferred drug list (MAPD)
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Lists preferred and non-preferred medically administered Part B drugs and notes step therapy and prior authorization practices for Aetna Medicare Advantage plans that offer prescription drug coverage (MAPD). Affects providers prescribing/administering Part B drugs to affected members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Utilization Management
General step therapy/coverage rule
Covered when ALL of the following are met
Exception process exists for documented clinical reasons; see linked step therapy criteria per drug.
Coverage annotations and utilization management
Coverage and utilization management annotations (prior authorization, step therapy) apply as specified per agent or category
See product-specific links for step therapy or prior authorization details.
Authorization requirements vary by agent; follow linked criteria.
When step therapy is specified, providers must document trials/failures per linked criteria.
Follow product-specific medical necessity links and fax forms when submitting requests.
See linked medical necessity criteria for Reblozyl.
Step therapy indications
Indications subject to step therapy (as listed in document)
Multiple immuno-oncology agents (e.g., Libtayo J9119, Keytruda J9271, Opdivo J9299, Tecentriq J9022) reference step therapy or link to step therapy criteria for these indications.
Prior authorization examples
Examples of prior authorization status
Coverage with criteria (excerpt)
Covered when specified product-specific medical necessity criteria are met and any step therapy requirements are satisfied
Bevacizumab (Avastin) is listed as prior authorization not required; other ophthalmic agents link to criteria.
Examples: Durolane and Synvisc-one listed as preferred; Gel-one and Monovisc listed as non-preferred (Hymovis One effective 4/1/2026).
Follow linked medical necessity and step therapy criteria for coverage determinations.
Coverage and routing overview
Drugs covered under Part B are listed with routing and whether step therapy applies; specific coverage is determined by referenced medical necessity/step therapy documents.
Providers must follow the routing and the linked criteria for each drug when submitting authorization requests.
Non-preferred products generally will not be approved for coverage until the member has tried the listed preferred product(s) for the same indication and those products have not been effective or are not tolerated. An exception process exists for clinical circumstances that justify use of a non-preferred product; providers should follow the exception process described in the linked criteria documents.
Some drug entries in the catalogue explicitly indicate that prior authorization is not required for specific agents or formulations. Examples in the excerpt include Neulasta Onpro (listed as “is not required”) and Procrit/Epogen entries noted as “Prior authorization is not required”; always follow the product-specific entry for authorization expectations.
The table shows that Paclitaxel (HCPCS J9267) is listed with medical necessity/prior authorization = is not required, indicating this agent is not subject to prior authorization per the excerpted listing.
Certain subcutaneous or self‑administered products are routed to the Medicare Part D (pharmacy) benefit rather than Part B; when an agent is handled under Part D it will not be processed as a Part B‑administered drug. Providers must check the routing noted in the catalogue entry (for example, multiple SC biologics are listed with “See Part D benefit” or “Request through Part D”).
This listing is informational and intended to guide selection of preferred Part B products; it does not replace the prescriber’s clinical judgment. For specific coverage determinations, exclusions, limitations and the formal exception processes, providers should consult the referenced medical necessity and step therapy criteria and the member’s Evidence of Coverage.
Within the provided excerpt there are no explicit statements declaring items “not medically necessary”. Authorization and coverage determinations are expressed via annotations such as required prior authorization, prior authorization not required, step therapy links, or routing to Part D.
HCPCS / Billing Codes by Category
| J2506 | Neulasta |
| J0885 | Procrit / Epogen |
| J0896 | Reblozyl |
| J9045 | Carboplatin |
What Providers Must Do
Prior authorization varies by product
Prior authorization requirements differ by product; some entries explicitly note prior authorization is required while others state it is not required (e.g., Zoledronic acid J3489 and Pamidronate J2430 are noted as prior authorization is not required).
Obtain prior authorization when the entry indicates it
When a drug entry lists 'Prior authorization' or 'Link to criteria', providers must obtain prior authorization per the referenced medical necessity criteria before requesting coverage.
- Neulasta (J2506) — Medical necessity criteria = Prior authorization; Fax request form referenced.
- Aranesp (J0881/J0882) — Medical necessity criteria = Prior authorization (agent‑specific).
- IV iron newer agents (Feraheme Q0139, Injectafer J1439, Monoferric J1437) — entries reference step therapy and links to criteria for authorization.
Follow the stated prior authorization status per drug
The table includes examples showing some drugs require prior authorization while others explicitly do not; follow the specific status shown for each agent.
Use HCPCS/J/Q codes and linked criteria for authorization
Many listed drugs include HCPCS/J/Q codes and indicate whether prior authorization is required or link to medical necessity criteria and fax forms; providers should use the HCPCS code shown and follow the linked criteria when submitting requests.
Follow HCPCS-coded drug routing and referenced criteria
Prior authorization requirements and routing differ for HCPCS‑coded drugs; many entries list an HCPCS code and reference a link to medical necessity and/or step therapy criteria that must be followed for authorization.
Try preferred Part B drugs first (step therapy)
The policy requires trial of preferred products before coverage of non‑preferred Part B drugs; providers must document prior use and failure of preferred agents per the step therapy rules.
- Preferred products listed should be used first; exception process exists for clinical reasons.
- See the corresponding step therapy criteria document on Aetna's website for product‑specific step requirements.
Follow linked step therapy criteria when indicated
When an agent or category is marked 'subject to step therapy' or provides a 'Step therapy criteria' link, providers must follow the linked step therapy criteria and document required prior trials or failures.
- Colony stimulating factors and long‑acting CSFs — Neulasta and biosimilars reference step/authorization links.
- Reblozyl (J0896) — links to criteria and step therapy for MDS‑related anemia.
- IV iron newer agents (Feraheme, Injectafer, Monoferric) — entries state 'See step therapy criteria' and link to criteria.
Step therapy applies to listed indications
Several categories and specific indications are noted as 'Indications subject to step therapy'; for those indications, providers must ensure required step therapy trials are met before requesting non‑preferred agents.
- Checkpoint inhibitors for squamous cell carcinoma and NSCLC — listed agents reference step therapy or links to criteria.
- Certain oncology indications (colon, rectal metastatic disease) — step therapy links provided for IO agents.
Step therapy required for several product categories
Multiple product categories are subject to step therapy (examples include viscosupplements and ophthalmic VEGF inhibitors); providers must follow product‑specific step therapy rules and document prior trials as required.
- Viscosupplements — preferred single‑ and multiple‑injection products listed; non‑preferred products have linked criteria.
- Ophthalmic VEGF inhibitors — trial of preferred products from both tiers required before approval of non‑preferred products.
Consult the corresponding step therapy criteria documents
The document explicitly identifies multiple drugs and indications as subject to step therapy and instructs providers to see the corresponding step therapy criteria documents on Aetna's website for specific requirements.
- Some agents are noted as 'None' for step therapy or routed to Part D; verify routing and step therapy status per the entry.
- Providers should consult the linked criteria for exact trial/failure definitions required for step exceptions.
Use the listed medical necessity links and fax forms
Many entries include links to medical necessity criteria and fax request forms for specific products; providers must use the referenced medical necessity links and fax forms when submitting authorization requests.
- Examples in the table show 'Link to criteria' and 'Link to fax form' entries for products such as Jubbonti and Prolia.
- Use the provided fax request form where shown to submit prior authorization information.
Submit prior authorization/fax form when indicated
Where a drug entry notes 'Prior authorization' or 'Link to criteria' plus a 'Fax request form', providers must submit the referenced prior authorization/fax form and supporting documentation as part of the authorization request.
- Neulasta entry references Prior authorization and a Fax request form; submit the form as instructed.
- Aranesp and Eligard entries show prior authorization notes or 'is not required' status — follow the specific instruction per agent.
Follow linked medical necessity criteria and fax forms
Many drug entries list links to medical necessity criteria and fax request forms (for example, Gammaked, Gamunex‑C, Hizentra, Xembify); providers must follow the referenced criteria and complete the specified fax forms when requesting coverage.
Submit the referenced medical necessity documentation or fax form
For each listed product with a referenced medical necessity criteria or fax form, providers must submit the required medical documentation or the specified fax request form when seeking prior authorization.
- Byooviz, Eylea and other ophthalmic agents show 'Link to criteria' and 'Link to fax form' — include required documentation per those links.
- Failure to submit the referenced documentation may delay or prevent authorization.
Use linked criteria and fax forms for HCPCS‑coded drug requests
Providers must reference the linked medical necessity and step therapy criteria and use the specified fax request forms (as provided in the catalogue) when submitting authorization requests for HCPCS‑coded drugs.
- Avsola, Inflectra, Renflexis and Remicade entries include links to criteria and fax forms — use those links/forms when requesting coverage.
- Cimzia and Orencia entries list HCPCS codes with links to criteria and fax forms; follow those links for authorization steps.
Noncompliance with step therapy may result in denial
Coverage may be limited or denied if step therapy requirements (trial of preferred drugs) are not met or if the exception process is not followed; ensure documentation of prior trials or approved exceptions is included with requests.
- Preferred products should be tried first; exceptions must be documented and follow the exception process.
- Requests lacking required step‑therapy documentation risk denial or routing to a different benefit.
Step therapy for some IV iron agents may lead to denial if unmet
Some IV iron agents (Feraheme, Injectafer, Monoferric) reference step therapy criteria; requests that do not meet the linked step therapy criteria may be denied.
Docetaxel (J9171) requires prior authorization
Docetaxel (J9171) is listed with Medical necessity criteria = Prior authorization; providers must obtain prior authorization per the entry before requesting coverage.
- Docetaxel, HCPCS code = J9171 — Medical necessity criteria explicitly lists 'Prior authorization'.
- Include the required prior authorization documentation and fax form as indicated.
Carboplatin documented as not requiring prior authorization
Carboplatin (J9045) is listed with 'Prior authorization is not required' in the table; verify other agents individually as some may still require authorization.
- Carboplatin, HCPCS code = J9045 — Medical necessity criteria = Prior authorization is not required.
- Do not assume authorization status for other platinum agents; check each entry.
Ophthalmic VEGF inhibitors require trials of preferred products from both tiers
For ophthalmic VEGF inhibitors, non‑preferred products require trial of preferred products from both tiers before approval; document trials of both tier‑preferred agents per the listed requirements.
- Bevacizumab (Avastin) is listed as 1st‑tier preferred with prior authorization not required; other ophthalmic agents reference step therapy links and fax forms.
- Providers must show trial/failure of preferred products from both tiers to support coverage of a non‑preferred ophthalmic VEGF inhibitor.
Verify Part B vs Part D routing to avoid routing/coverage risk
Requests for drugs that are routed to Part D or that are subject to step therapy may be routed or denied if the prescribing/coverage pathway is incorrect; verify whether the product is processed under Part B or Part D before submitting.
- Many SC/self‑administered products are handled under Part D — entries note 'See Part D benefit' or 'Request through Part D'.
- Submitting a Part B prior authorization for a product covered under Part D can result in routing delays or denials.
Background and Scope
This document groups medically administered Medicare Part B drugs by therapeutic category and annotates each entry with utilization management information where applicable, including whether step therapy applies or whether a prior authorization or linked medical necessity criteria and fax request form are required. Where step therapy is specified, the policy requires that listed preferred products be tried first and that providers follow the linked step therapy criteria to document prior use or failure of preferred agents.
Definitions and Terms
Initial Therapy Requirements
Initial therapy requirement
Preferred products listed should be used first
An exception process exists for documented clinical reasons; see linked step therapy criteria.
Initial therapy rules (agent-specific)
Initial authorization depends on agent-specific criteria and whether step therapy applies.
Follow the specific Neulasta product criteria and fax request instructions as applicable.
Provider must follow product-specific medical necessity links for initial authorization.
Ophthalmic initial step
VEGF inhibitors (ophthalmic)
Bevacizumab (Avastin) is listed as prior authorization not required; other ophthalmic agents reference links to criteria and may require authorization.
Step Therapy Rules
| Requirement | Details |
|---|---|
| Step therapy requirement | Trial and failure of preferred product(s) for the drug class/indication is required before coverage of a non-preferred product; see the product- or class-specific 'Step therapy criteria' links in the catalogue for exact agents and failure definitions. |
| Exception process | An exception process exists for specific clinical circumstances that justify use of a non-preferred product prior to completing step therapy. |
| Provider obligation | Source / Note |
|---|---|
| Follow linked criteria when step therapy listed | When an agent or category entry lists 'Step therapy criteria' or references a link to criteria, providers must follow the referenced step therapy criteria for that drug or class (examples: colony stimulating factors, Reblozyl, IV iron entries). |
| Document prior use/failure per criteria | Requests must document prior use and failure or intolerance of required preferred agents as specified in the linked step therapy criteria documents. |
| Indications subject to step therapy | Examples / Notes |
|---|---|
| Squamous cell carcinoma | Checkpoint inhibitors (e.g., Libtayo) are listed under indications subject to step therapy; see the linked step therapy criteria for drug-specific requirements. |
| Non-small cell lung cancer (NSCLC) | Multiple immuno-oncology agents (Keytruda, Opdivo, Tecentriq, etc.) reference step therapy or link to step therapy criteria for listed indications. |
| Unresectable, inoperable, or metastatic colon/rectal cancer | Certain checkpoint inhibitors used in metastatic colon or rectal cancer are listed as subject to step therapy; follow the linked criteria for specifics. |
| Product categories with step therapy | Policy detail / requirement |
|---|---|
| Ophthalmic VEGF inhibitors | Preferred products from both tiers must be tried prior to receiving a non-preferred ophthalmic VEGF inhibitor; bevacizumab (Avastin) is listed as prior authorization not required while other agents link to criteria. |
| Viscosupplements (single and multiple injection) | Some viscosupplement products are preferred and require no prior authorization; non-preferred viscosupplements reference step therapy or link to criteria — see the catalogue entries for product-specific requirements. |
| Immunologics / infliximab products | Several infliximab and biosimilar products are listed with links to medical necessity and step therapy criteria; preferred vs non-preferred routing (including Part D routing) is determined by the referenced criteria. |
| Drugs/indications designated for step therapy | Reference / action |
|---|---|
| Various biologics routed to Part D (e.g., psoriasis, RA agents) | Multiple SC biologic products (psoriasis, rheumatoid arthritis agents) are noted 'See Part D benefit' or 'Request through Part D' and may list step therapy criteria or none; follow the Part D routing notes and linked criteria. |
| Infliximab and biosimilars (Avsola, Inflectra, Renflexis, Remicade, unbranded J1745) | These agents include links to medical necessity and step therapy criteria; providers must follow the referenced step therapy documents when the listing indicates step therapy applies. |
| Rheumatologic biologics (e.g., Actemra, Cimzia, Orencia, Leqvio) | Several rheumatology biologics are listed with HCPCS codes and linked step therapy criteria; where entries reference 'See Part D benefit' follow the routing instructions and step therapy links for authorization requirements. |
Site of Care and Benefit Routing
Site‑of‑care not specified in this excerpt
Site‑of‑care details are not specified in this excerpt; check product‑specific entries and linked criteria for any site‑of‑care or benefit routing instructions.
- The catalogue does not specify infusion site requirements here; review the linked medical necessity criteria for site‑of‑care rules.
Process SC products through Part D when indicated
Some subcutaneous products are handled through the Part D (pharmacy) benefit rather than Part B; when entries indicate 'See Part D benefit' or 'Request through Part D', submit requests through the Part D pathway.
- Examples include SC biologics listed with 'See Part D benefit' (e.g., Tremfya SC, Skyrizi SC) — process through Part D as instructed.
- Confirm benefit routing before submitting a Part B prior authorization to avoid denial or routing delays.
Biosimilars and Preferred Product Notes
Xgeva / Prolia category entries reference biosimilar criteria
Preferred and biosimilar Xgeva/Prolia category products are listed with HCPCS codes and some biosimilars include links to medical necessity and step therapy criteria; follow the referenced criteria for authorization and preference rules.
Neulasta entries include HCPCS and prior authorization notes
Neulasta entries list HCPCS codes and authorization notes; Neulasta (J2506) is annotated as requiring prior authorization while Neulasta Onpro is noted as not requiring prior authorization in the table.
Neulasta biosimilars reference linked criteria for authorization
Another Neulasta biosimilar entry (Udenyca Q5111 and other biosimilars) references linked criteria for step therapy/prior authorization; follow those links for authorization requirements.
Herceptin biosimilars reference criteria links
Herceptin biosimilars (e.g., Kanjinti Q5117) are listed with HCPCS codes and links to criteria for some biosimilars; follow those links for coverage and authorization details.
Remicade and infliximab biosimilars reference HCPCS codes and criteria
Infliximab branded and biosimilar products (Remicade and biosimilars) list HCPCS codes and link to medical necessity criteria and fax forms; preferred product determination and routing depend on the referenced criteria.
Avsola (Q5121) requires following linked criteria
Avsola (Q5121) is listed with HCPCS code and links to medical necessity and step therapy criteria; preference and routing are determined by the referenced criteria and must be followed when requesting coverage.
- Avsola (Q5121) — Medical necessity criteria = Link to criteria; Step therapy criteria = Link to criteria; Fax request form referenced.
- Use the linked criteria to determine whether Avsola is preferred and to obtain required authorization.
Inflectra (Q5103) references linked criteria for authorization
Inflectra (Q5103) is listed with HCPCS code and links to medical necessity and step therapy criteria; providers must follow those links for authorization and routing.
- Inflectra (Q5103) — Medical necessity criteria = Link to criteria; Step therapy criteria = Link to criteria; Fax request form referenced.
- Follow the referenced criteria to determine preference and required documentation.
Renflexis (Q5104) requires adherence to linked criteria and forms
Renflexis (Q5104) is listed with HCPCS code and link(s) to criteria; providers must follow the linked medical necessity and fax forms when requesting authorization.
- Renflexis (Q5104) — Medical necessity criteria = Link to criteria; Step therapy criteria = Link to criteria in some entries.
- Use the provided links and fax forms to submit required documentation for authorization.
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