Medicare Part B Drug Prior Authorization Criteria
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Defines prior authorization requirements for selected Medicare Part B drugs administered by providers under Providence Medicare Advantage Plans; affects providers seeking coverage for listed Part B medications for plan members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Prior Authorization Overview
General prior authorization requirement
Prior authorization coverage applies to the listed Part B drugs when plan approval is obtained in advance.
See individual drug policy links for specific clinical criteria
If a required prior authorization is not obtained from Providence Medicare Advantage Plans before administration of a listed Part B drug, the plan may not cover the drug. Providers and ordering clinicians must secure plan approval in advance per the listed drug-specific requirements to avoid denial of coverage.
HCPCS/CPT/Q/J Codes and Medication Listings
| J9395 | Faslodex (Fulvestrant) |
| J1951 | Fensolvi (Leuprolide acetate) |
| J1572 | Flebogamma (Immune globulin) |
| J1325 | Flolan, Veletri (Epoprostenol) |
| J9394 | Fulvestrant (fresenius kabi) |
| J9393 | Fulvestrant (teva) |
| J9331 | Fyarro (Sirolimus protein-bound particles) |
| Q5130 | Fylnetra (Pegfilgrastim-pbbk) |
| S0132 | Fyremadel (Ganirelix acetate) |
| J1460 | GamaSTAN S/D (Immune globulin) |
| J1566 | Gammagard S-D (Immune globulin) |
| J1561 | Gammaked / Gamunex-C (Immune globulin) |
| J1557 | Gammaplex (Immune globulin) |
| J1554 | Asceniv (Immune globulin) |
| J1552 | Alyglo (Immune globulin) |
| J1599 | Immune globulin, intravenous, non-lyophilized, NOS |
| J0614 | Grafapex (Treosulfan) |
| J0614 | Grafapex (Treosulfan) - duplicate for emphasis |
| J9179 | Halaven (Eribulin mesylate) |
| J1411 | Hemgenix (Etranacogene dezaparvovec-drlb) |
Provider Actions, Authorization Steps, and Billing Notes
Prior Authorization Required
Prior authorization is required for the Medicare Part B drugs listed below. Providers must obtain approval before administration/claim submission; claims for listed HCPCS/CPT/Q/C codes submitted without an approved prior authorization may be denied or not covered.
- Provider contact for prior authorization: Providence Medicare Advantage Plans at 503-574-8000 or 1-800-603-2340. TTY: 711. Hours: daily 8 a.m.–8 p.m. PT (seasonal weekend closures Apr 1–Sep 30).
- This list includes many specialty injectable and infusible drugs — utilization management (including prior authorization) applies to these therapies to ensure appropriate use and site-of-care considerations.
- Failure to obtain required prior authorization can result in claim denials or non-coverage; obtain PA before treatment to avoid member liability.
Medicare Part B Drugs Requiring Prior Authorization (sample)
Sample entries (each drug has a policy criteria link — click to view the full clinical criteria and any effective date notes). Use the linked policy for the specific medical necessity and documentation requirements for initial and continuation therapy.
Documentation and Policy Links Provided per Drug
Documentation and direct policy links are provided for each listed drug. Before submitting a PA request, consult the drug-specific policy ("Click to view") for required clinical documentation, code(s), and any Effective Date that impacts when the PA requirement starts.
- Each listed entry includes HCPCS/CPT/Q-code, medication name, and a "Click to view" link to the policy criteria.
- Some entries include an "Effective Date (if after 1/1/2026)" annotation — consult the drug policy for the exact effective date when the PA requirement begins.
Utilization Management Note
Specialty injectables and infusible drugs on this list may also be subject to additional utilization management (e.g., quantity limits, site-of-care review, step requirements). Review the specific drug policy for any utilization management rules that apply.
- Utilization management may include: site-of-care review, quantity limits, medical necessity criteria, and requirement to use preferred product when applicable.
- If utilization management rules exist (including step therapy), they will be documented on the drug-specific "Click to view" policy page.
Step Therapy (see individual drug policies)
Step therapy: No universal step therapy rules are specified in this section excerpt. If a drug requires step therapy, the drug-specific policy (linked via "Click to view") will state the required prior steps and alternatives.
- Consult each drug's policy link for any step-therapy requirements or exceptions.
Background and Purpose
Prior authorization is used to ensure appropriate use of certain medications — particularly specialty drugs administered by providers (injections or infusions). Requiring plan approval before administration helps the health plan confirm that the drug is medically necessary, used in the correct clinical circumstances, and procured and billed according to Providence Medicare Advantage Plans policies.
Key Definitions
Site-of-Care Notes
Infusion/administration site: prior authorization applies
Drugs administered by providers (injectable or infused) are subject to prior authorization; see the individual drug policy links for site-of-care guidance (infusion center or other settings).
- The policy directs providers to individual drug policies for site-of-care specifics.
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