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CurrentAetnaPolicy Y0001_NR_4168508_2025_C 4168505-01-01

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.

Policy Summary

PayerAetna

PolicyMedicare Part B preferred drug list (MAPD)

Policy CodePolicy Y0001_NR_4168508_2025_C 4168505-01-01

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must submit referenced prior authorization/fax forms and follow linked step therapy and medical necessity criteria when a drug entry specifies prior authorization or step therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecategories listed (partial document)

step therapy notedstep therapy applies to many indications

fax/PA refsforms and prior auth mentioned

HCPCScoding system used

distinct agents/biosimilars named

Coverage Criteria and Utilization Management

General step therapy/coverage rule

Covered when ALL of the following are met

Step therapy first-line: Provider has tried preferred product(s) for the indication prior to requesting a non-preferred product, per class- or drug-specific step therapy criteria linked in the catalogue.

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

Colony stimulating factors (long-acting): Neulasta (J2506) is listed with 'Prior authorization'; Neulasta Onpro (J2506) is noted as 'is not required' for prior authorization. Multiple biosimilars (Fulphila Q5108, Fylnetra Q5130, Nyvepria Q5122, Stimufend Q5127, Udenyca Q5111) are listed with links or references to criteria.

See product-specific links for step therapy or prior authorization details.

Erythropoiesis stimulating agents: Procrit/Epogen (J0885) is noted as prior authorization is not required for some entries; Aranesp (J0882/J0881) is listed with 'Prior authorization'. Retacrit (Q5106) and other biosimilars reference links to criteria.

Authorization requirements vary by agent; follow linked criteria.

IV iron: Older IV iron products (Ferrlecit J2916, sodium ferric gluconate J1750, Venofer J1756) are noted as 'Prior authorization is not required'; newer agents (Feraheme Q0139, Injectafer J1439, Monoferric J1437) reference step therapy criteria and link to step therapy documents.

When step therapy is specified, providers must document trials/failures per linked criteria.

IVIG / SCIG: Multiple IVIG and SCIG products (e.g., Gammaked J1561, Gamunex-C J1561, Privigen J1459, Hizentra J1559, Xembify J1558) are listed with links to medical necessity criteria; some have no step therapy while others reference criteria links and fax forms.

Follow product-specific medical necessity links and fax forms when submitting requests.

Reblozyl (J0896) is listed for very low to intermediate‑risk MDS-related anemia and links to criteria and step therapy where applicable.very low to intermediate-risk MDS

See linked medical necessity criteria for Reblozyl.

Step therapy indications

Indications subject to step therapy (as listed in document)

Indications subject to step therapy: Squamous cell carcinoma; Non-small cell lung cancer; Unresectable, inoperable, or metastatic colon cancer; Metastatic rectal cancer.

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

Prior authorization requirements: Docetaxel (J9171) — prior authorization indicated; Carboplatin (J9045) — prior authorization is not required; Halaven (J9179) — prior authorization is not required.

Other agents include 'Link to criteria' or fax forms for details.

Coverage with criteria (excerpt)

Covered when specified product-specific medical necessity criteria are met and any step therapy requirements are satisfied

VEGF inhibitors (ophthalmic): Preferred products from both tiers must be tried prior to receiving a non-preferred ophthalmic VEGF inhibitor.trial of preferred products from both tiers

Bevacizumab (Avastin) is listed as prior authorization not required; other ophthalmic agents link to criteria.

Viscosupplements (single and multiple injection): Preferred viscosupplements are listed and may not require prior authorization; non-preferred products reference medical necessity criteria or prior authorization as indicated.product-specific prior authorization or criteria as linked

Examples: Durolane and Synvisc-one listed as preferred; Gel-one and Monovisc listed as non-preferred (Hymovis One effective 4/1/2026).

Immunologics (selected indications): Some formulations (notably SC self-administered products) may be routed to the Part D benefit; when covered under Part B, product-specific medical necessity criteria and step therapy links apply.

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.

Routing categories: Some agents/formulations are processed through the Part D (pharmacy) benefit (noted as 'See Part D benefit' or 'Request through Part D'); others have HCPCS codes and link to Part B medical necessity/step therapy criteria.

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

Alpha-1 proteinase inhibitorsHCPCS

J0256	Alpha-1 proteinase inhibitor (listed)
J0257	Alpha-1 proteinase inhibitor (listed)

Selected HCPCS codes by category (partial)HCPCS

J3489	Zoledronic acid
Q5136	Jubbonti / Wyost (listed biosimilars/misc)
J0897	Prolia / Xgeva
J3111	Evenity
Q5158	Conexxence
Q5159	Ospomyv / Xbryk
J0585	Botox
J0586	Dysport / other botulinum toxins
J0587	Myobloc
J0589	Daxxify

1–10 of 30

1/3

Colony stimulating factors (examples)HCPCS

J2506

Neulasta

Erythropoiesis stimulating agentsHCPCS

J0885

Procrit / Epogen

ReblozylHCPCS

J0896

Reblozyl

Intravenous iron agentsHCPCS

J2916	Ferrlecit
J1750	Sodium ferric gluconate
J1756	Venofer
Q0139	Feraheme
J1439	Injectafer
J1437	Monoferric

IVIG and SCIG agentsHCPCS

J1561	Gammaked / Gamunex-C (IVIG)
J1459	Privigen
J1552	Alyglo
J1554	Asceniv
J1572	Flebogamma
J1569	Gammagard Liquid
J1557	Gammaplex
J1568	Octagam
J1576	Panzyga
J3590/C9399	Yimmugo (misc codes)

1–10 of 15

1/2

Factor VIII (recombinant) agentsHCPCS

J7211	Kovaltry
J7209	Nuwiq
J7192	Advate
J7210	Afstyla
J7182	NovoEight
J7185	Xyntha

Multiple sclerosis agentsHCPCS

J2350	Ocrevus
J2351	Ocrevus Zunovo

Gonadotropin-releasing hormone agonists/antagonistsHCPCS

J9217	Eligard / Lupron depot (listed under same code in excerpt)
J3315	Trelstar
J9202	Zoladex
J9155	Firmagon

Other immunologics (examples)HCPCS

J3380	Entyvio IV
J1628	Tremfya IV

SCIG / Immunoglobulins (selected)HCPCS

J1561	Gammaked, Gamunex-C
J1559	Hizentra
J1558	Xembify

SCIG / Immunoglobulins (additional)HCPCS

J1551	Cutaquig
J1555	Cuvitru
J1575	HyQvia
J1569	Gammagard Liquid

Multiple sclerosis agentsHCPCS

J2350	Ocrevus
J2351	Ocrevus Zunovo

Multiple sclerosis / related biologicsHCPCS

J2329	Briumvi
J0202	Lemtrada
J2323	Tysabri

Breast cancer / taxanesHCPCS

J9306	Perjeta
J9171	Docetaxel
J9267	Paclitaxel
J9264	Abraxane (protein-bound paclitaxel)

Avastin and biosimilarsHCPCS

Q5107	Mvasi
Q5118	Zirabev
J9035	Avastin

Bendamustine products and relatedHCPCS

J9033	Treanda
J9058	Bendamustine
J9056	Vivimusta (effective 4/1/2026)

Carboplatin productsHCPCS

J9045

Carboplatin

Herceptin and biosimilarsHCPCS

Q5117	Kanjinti
Q5112	Ontruzant
J9355	Herceptin
J9356	Herceptin Hylecta

Rituxan and biosimilarsHCPCS

Q5119	Ruxience
Q5115	Truxima
Q5123	Riabni
J9312	Rituxan
J9311	Rituxan Hycela

Selected oncology agents (multiple myeloma, liposarcoma)HCPCS

J9179	Halaven
J9352	Yondelis
J9046	Bortezomib
J9145	Darzalex

Immuno-oncology, pemetrexed, osteoarthritis injections, somatostatin analoguesHCPCS

J9119	Libtayo
J9271	Keytruda
J9299	Opdivo (listed as J9299)
J9022	Tecentriq
J9305	Alimta
J9294	Pemetrexed (grouped J9294/J9296/J9297/J9314)
J9304	Pemfexy
J9292	Axtle
J9324	Pemrydi RTU
J3304	Zilretta

1–10 of 13

1/2

Covered HCPCS/J/Q Codes (excerpt)HCPCSCovered

C9257	Bevacizumab (Avastin) HCPCS
J7999	Bevacizumab (Avastin) miscellaneous HCPCS
Q5124	Byooviz HCPCS
J0178	Eylea HCPCS
J0177	Eylea HD HCPCS
Q5147	Pavblu HCPCS
J0179	Beovu HCPCS
Q5128	Cimerli HCPCS
J2778	Lucentis HCPCS
J2779	Susvimo HCPCS

1–10 of 33

1/4

HCPCS codes listedHCPCS

J1745	Remicade; Unbranded infliximab
J0717	Cimzia
J0129	Orencia
Q5103	Inflectra
Q5104	Renflexis
Q5121	Avsola
J3245	Ilumya
J1602	Simponi Aria
J2182	Nucala
J3032	Vyepti

1–10 of 19

1/2

MDS risk category — Reblozyl

MDS risk categoryVery low to intermediate‑risk myelodysplastic syndromes (MDS) — Reblozyl indicated for MDS‑related anemia

Associated HCPCS codeJ0896 (Reblozyl)

What Providers Must Do

Prior Authorization

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).

Zoledronic acid (J3489) — Medical necessity criteria = Prior authorization is not required.
Pamidronate (J2430) — Medical necessity criteria = Prior authorization is not required.
Neulasta (J2506) — Medical necessity criteria = Prior authorization (per listing).

Prior Authorization

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.

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

Step therapy — definition

DefinitionStep therapy requires trying specified preferred drug(s) for an indication before covering a non‑preferred alternative

PurposeTo ensure use of preferred, clinically appropriate, or lower‑cost agents first; exceptions can be requested for clinical reasons

Provider actionFollow the corresponding step therapy criteria document linked for each drug/class when the listing indicates step therapy

IV iron — indication

Indication summaryIntravenous iron indicated for iron deficiency anemia after intolerance to or unsatisfactory response to oral iron, or for patients with chronic kidney disease

Common agents (HCPCS)Ferrlecit (J2916), Sodium ferric gluconate (J1750), Venofer (J1756)

Initial Therapy Requirements

Initial therapy requirement

Preferred products listed should be used first

Try preferred product: Member should be started on the listed preferred product(s) for the drug class/indication prior to coverage of non-preferred alternatives, per step therapy rules.

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.

Neulasta vs Neulasta Onpro: Neulasta (J2506) is listed with 'Prior authorization'; Neulasta Onpro (J2506) is noted as 'is not required' for prior authorization and has 'None' for step therapy in the listing.

Follow the specific Neulasta product criteria and fax request instructions as applicable.

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

Note

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.

Billing Rule

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.

Biosimilars and Preferred Product Notes

Billing Rule

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.

Xgeva (J0897) and Wyost (Q5136) entries include 'Link to criteria' and 'Link to fax form'.
Use the listed HCPCS code and linked criteria to determine preferred/biosimilar routing and authorization steps.

Billing Rule

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 (J2506) — Medical necessity criteria = Prior authorization; Fax request form referenced.
Neulasta Onpro (J2506) — Medical necessity criteria = is not required; Step therapy criteria = None.

Policy Summary

PayerAetna

PolicyMedicare Part B preferred drug list (MAPD)

Policy CodePolicy Y0001_NR_4168508_2025_C 4168505-01-01

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must submit referenced prior authorization/fax forms and follow linked step therapy and medical necessity criteria when a drug entry specifies prior authorization or step therapy.

SourceLink

On This Page

See Part D benefit for some SC products; Part B HCPCS listed for IV products.

Follow linked medical necessity and step therapy criteria for coverage determinations.

Authorization linksReblozyl references linked medical necessity and step therapy criteria and a fax request form

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.

Prior 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.

Docetaxel (J9171) — Medical necessity criteria = Prior authorization.
Carboplatin (J9045) — Medical necessity criteria = Prior authorization is not required.
Halaven (J9179) — Medical necessity criteria = Prior authorization is not required.

Billing Rule

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.

Bevacizumab (Avastin) — C9257 / J7999; Medical necessity criteria = prior authorization is not required for bevacizumab (Avastin).
Eylea (J0178) and other ophthalmic VEGF agents — HCPCS codes listed with links to criteria and fax forms.

Billing Rule

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.

Avsola (Q5121), Inflectra (Q5103), Renflexis (Q5104), Remicade (J1745) — HCPCS codes shown with links to criteria and fax forms.
Cimzia (J0717) and Orencia (J0129) — HCPCS codes and links to medical necessity/step therapy criteria for authorization.

Step Therapy

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.

Step Therapy

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

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

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.

Note

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.

Documentation Required

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.

Prior Authorization

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.

Documentation Required

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.

Gammaked (J1561) and Gamunex‑C (J1561) — 'Link to criteria' and 'Link to fax form' indicated.
Hizentra (J1559) and Xembify (J1558) — criteria and fax request form links shown; use them for authorization.

Documentation Required

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.

Documentation Required

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.

Denial Risk

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.

Denial Risk

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.

Feraheme (Q0139/Q0138), Injectafer (J1439), Monoferric (J1437) — 'See step therapy criteria' and links are provided; follow those criteria to avoid denial.
Preferred older IV iron agents (Ferrlecit J2916, sodium ferric gluconate J1750, Venofer J1756) are noted as prior authorization not required.

Prior Authorization

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.

Note

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.

Step Therapy

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.

Denial Risk

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.

Utilization managementSome newer IV iron agents (Feraheme Q0139, Injectafer J1439, Monoferric J1437) reference step therapy or linked criteria

Reblozyl indication

IndicationReblozyl is indicated for anemia related to very low to intermediate‑risk myelodysplastic syndromes (MDS)

HCPCS codeJ0896

Authorization notesReblozyl entry includes links to medical necessity and step therapy criteria and a fax request form

HCPCS code — Level II HCPCS (J/Q) codes

DefinitionLevel II HCPCS (J‑ and Q‑codes) identify infused and injected drugs billed under Medicare Part B

ExamplesBevacizumab (Avastin) C9257 / J7999; Mvasi Q5107; Zirabev Q5118

UseHCPCS codes in this list link to medical necessity/step therapy criteria and fax request forms when applicable

Preferred product from both tiers — VEGF inhibitors (ophthalmic)

RequirementFor ophthalmic VEGF inhibitors, trial of preferred products from both tiers is required before coverage of a non‑preferred product

Example preferred agentBevacizumab (Avastin) noted as 1st‑tier preferred with prior authorization not required

Provider implicationDocument trials of preferred products from both tiers per the linked criteria to avoid denial

Part D benefit routing

DefinitionPart D benefit routing: some subcutaneous or self‑administered products are processed under the Medicare Part D pharmacy benefit rather than Part B

Examples/notesCertain SC biologics (e.g., psoriasis, rheumatoid arthritis agents) list 'See Part D benefit' or 'Request through Part D' in the catalogue

ImpactProviders must route requests to the correct benefit (Part B vs Part D) per the listing; incorrect routing may result in denial or delay

Procrit/Epogen (J0885) entries indicate prior authorization is not required in some listings; Aranesp (J0882/J0881) is listed with 'Prior authorization'. Retacrit (Q5106) references linked criteria for authorization and step therapy.

Provider must follow product-specific medical necessity links for initial authorization.

Ophthalmic initial step

VEGF inhibitors (ophthalmic)

Tiered preferred trial: Trial of preferred products from both tiers is required before non-preferred ophthalmic VEGF inhibitors will be approved.trial of both tier preferred products

Bevacizumab (Avastin) is listed as prior authorization not required; other ophthalmic agents reference links to criteria and may require authorization.

Confirm benefit routing before submitting a Part B prior authorization to avoid denial or routing delays.

Billing Rule

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.

Udenyca (Q5111) — Medical necessity criteria = Link to criteria.
Fulphila (Q5108), Fylnetra (Q5130) — listed with HCPCS and links or blank criteria fields; use product‑specific criteria.

Billing Rule

Avastin and biosimilars reference HCPCS codes and criteria links

Avastin and its biosimilars (Mvasi Q5107, Zirabev Q5118) are listed with HCPCS codes; some biosimilars reference links to medical necessity criteria which must be followed for authorization and routing.

Mvasi (Q5107) and Zirabev (Q5118) — HCPCS codes shown; Zirabev includes 'Link to criteria' in some entries.
Avastin (J9035) — HCPCS code listed; consult linked criteria for agent‑specific rules.

Billing Rule

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.

Kanjinti (Q5117) — Medical necessity criteria = Link to criteria.
Herceptin (J9355) and Ontruzant (Q5112) — HCPCS codes listed; verify linked criteria for authorization.

Billing Rule

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.

Remicade (J1745), Avsola (Q5121), Inflectra (Q5103), Renflexis (Q5104) — HCPCS codes shown with links to criteria and fax forms.
Some infliximab products may be covered under Part D depending on formulation; consult the listed routing and criteria.

Billing Rule

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.

Billing Rule

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.

Billing Rule

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.