Providence Medicare Advantage Plans 2026 Prior Authorization Criteria for Part B Drugs
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This document lists Providence Medicare Advantage Plans' prior authorization requirements for selected Medicare Part B drugs (infused or injected) and provides contact information for providers and members about obtaining prior authorization. It affects Providence Medicare Advantage Plan members and their prescribing providers.
No material clinical or coverage changes in this revision.
Medicare Part B Drugs Requiring Prior Authorization
List of Part B drugs requiring prior authorization
The document enumerates Medicare Part B drugs (injected or infused) that require prior authorization and, where available, provides a link to the policy criteria and an effective-date flag.
ALL of the following
Part B drugs subject to prior authorization include (examples):
- Q2055 — Abecma (Idecabtagene vicleucel) (Click to view policy criteria).
- J9264 — Abraxane (Paclitaxel protein-bound particles) (Click to view policy criteria).
- J3262 — Actemra (Tocilizumab) (Click to view policy criteria).
- J0791 — Adakveo (Crizanlizumab-tmca) (Click to view policy criteria).
- J9042 — Adcetris (Brentuximab vedotin) (Click to view policy criteria).
- J9029 — Adstiladrin (Nadofaragene firadenovec) (Click to view policy criteria).
- J7171 — Adzynma (ADAMTS13, recombinant-krhn) (Click to view policy criteria).
- J9302 — Arzerra (Ofatumumab) (Click to view policy criteria).
- J1554 — Asceniv (Immune globulin) (Click to view policy criteria).
- J9118 — Asparlas (Calaspargase pegol-mknl) (Click to view policy criteria).
- Q2058 — Aucatzyl (Obecabtagene autoleucel) (Click to view policy criteria).
- Q5161 — Aukelso/Bosaya (denosumab-kyqq) (Click to view policy criteria; example effective date 4/1/2026).
- J9035 — Avastin (Bevacizumab) (Click to view policy criteria).
- J3145 — Aveed (Testosterone undecanoate) (Click to view policy criteria).
- Q5121 — Avsola (Infliximab-axxq) (Click to view policy criteria).
- A4253 — Diabetic DME Test Strips (Document link: Click to view).
- J9172 — Docivyx (Docetaxel) (Click to view policy criteria).
- J7351 — Durysta (Bimatoprost intracameral implant) (Click to view policy criteria).
- J0586 — Dysport (AbobotulinumtoxinA) (Click to view policy criteria).
- J9063 — Elahere (Mirvetuximab soravtansine-gynx) (Click to view policy criteria).
- J1743 — Elaprase (Idursulfase) (Click to view policy criteria).
- J3060 — Elelyso (Taliglucerase alfa) (Click to view policy criteria).
- This list is illustrative — the full roster contains many additional HCPCS/J-codes and mapped drug names; for each listed code a document link labeled 'Click to view' indicates where the detailed prior authorization criteria can be reviewed.
Listed Part B drugs and links to prior authorization criteria
Roster of additional Part B drugs with HCPCS/J-codes and document links to their prior authorization criteria; many entries include an 'if after 1/1/2026' effective-date flag.
ALL of the following
Representative listings include:
- J9021 — Rylaze (Asparaginase, recombinant) (Click to view policy criteria).
- J3402 — Ryoncil (Remestemcel-l-rknd) (Click to view policy criteria).
- J2998 — Ryplazim (Plasminogen, human-tvmh) (Click to view policy criteria).
- J9333 — Rystiggo (Rozanolixizumab-noli) (Click to view policy criteria).
- J0870 — Rytelo (Imetelstat) (Click to view policy criteria).
- J9361 — Ryzneuta (Efbemalenograstim alfa-vuxw) (Click to view policy criteria).
- J2353 — Sandostatin LAR Depot (Octreotide acetate, microspheres) (Click to view policy criteria).
- J9202 — Zoladex (Goserelin acetate implant) (Click to view policy criteria).
- J3399 — Zolgensma (Onasemnogene abeparvovec-xioi) (Click to view policy criteria).
- J9282 — Zusduri (Mitomycin) (Click to view policy criteria).
- J9359 — Zynlonta (Loncastuximab tesirine-lpyl) (Click to view policy criteria).
- J3393 — Zynteglo (Betibeglogene autotemcel) (Click to view policy criteria).
- J9345 — Zynyz (Retifanlimab-dlwr) (Click to view policy criteria).
- For the complete roster and to review the specific prior authorization requirements for a given HCPCS/J-code, use the document link labeled 'Click to view' associated with that code.
Procedure and HCPCS/J Codes
| source | Entries shown include clickable policy criteria links and optional 'if after 1/1/2026' effective-date fields. |
| source | Entries include 'click to view' links and optional 'if after 1/1/2026' effective-date fields. |
| Q5130 | Fylnetra (Pegfilgrastim-pbbk). |
| S0132 | Fylnetra / Fyremadel (Ganirelix acetate) references. |
| J1460 | GamaSTAN S/D (Immune globulin). |
| J1569 | Gammagard Liquid (Immune globulin). |
| J1566 | Gammagard S-D (Immune globulin). |
| J1561 | Gammaked / Gamunex-C (Immune globulin). |
| J1557 | Gammaplex (Immune globulin). |
| J0223 | Givlaari (Givosiran). |
| J0257 | Glassia (Alpha 1 proteinase inhibitor (human)). |
| J9301 | Gazyva (Obinutuzumab). |
| source | Each entry includes a 'Click to view' link for policy criteria; some list an 'if after 1/1/2026' effective date. |
| J9061 | Rybrevant (Amivantamab-vmjw) / Rybrevant Faspro. |
| J9021 | Rylaze (Asparaginase, recombinant). |
| J3402 | Ryoncil (Remestemcel-l-rknd). |
| J2998 | Ryplazim (Plasminogen, human-tvmh). |
| J9333 | Rystiggo (Rozanolixizumab-noli). |
| J2353 | Sandostatin LAR Depot (Octreotide acetate, microspheres). |
| J9227 | Sarclisa (Isatuximab-irf) / Saphnelo (Anifrolumab-fnia). |
| J3590/C9399 | Skysona (Elivaldogene autotemcel) / Soliris (Eculizumab). |
| J2326 | Spinraza (Nusinersen). |
| J2323 | Tysabri (Natalizumab). |
| effective_date_note | Many entries include an 'if after 1/1/2026' field (often blank or with a later date). |
What Providers Must Do
Prior authorization required for selected Medicare Part B drugs
Providence Medicare Advantage Plans requires prior authorization for certain Medicare Part B medications (injected or infused) before the plan will agree to cover them; lack of prior authorization may result in non-coverage.
How to request prior authorization / contact information
For questions or to request prior authorization, call Providence Medicare Advantage Plans at 503-574-8000 or 1-800-603-2340. TTY users should call 711; customer service hours are seven days a week, 8 a.m. to 8 p.m. PT (seasonal weekend hours noted in header).
Prior authorization drug/code roster with links and effective-date flags
The document lists multiple HCPCS/J (and other procedure) codes paired with medication names and provides a document link labeled 'Click to view' for each entry; many entries also include an 'if after 1/1/2026' effective-date field that may indicate when criteria apply.
- Entries show: Code, Medication Name, (click to view the policy criteria) and (if after 1/1/2026) fields.
- Many listed entries include a clickable 'Click to view' policy criteria link.
Part B drug prior authorization listing with document links
The Parts B drug listing enumerates specific HCPCS/CPT/procedure codes paired with medication names (for example Q5130 = Fylnetra; J9061 = Rybrevant; J9021 = Rylaze) and shows a 'Click to view' document link for each code; several entries include an 'if after 1/1/2026' value (some are 5/1/2026 or blank).
Terminology and Field Definitions
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