Providence Medicare Advantage Plans 2026 Prior Authorization Criteria for Part B Drugs
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Prior authorization requirements for certain Medicare Part B–covered drugs for Providence Medicare Advantage Plans effective 7/1/2026; applies to members and prescribing providers who seek coverage for listed Part B drugs.
No material clinical or coverage changes in this revision.
Medicare Part B Drug Prior Authorization — Covered Criteria Index
Listed Part B drugs and link to criteria
The document lists Medicare Part B drugs subject to prior authorization and provides a link to view the specific prior authorization criteria for each listed drug.
Drug listing and link directory
Indexed medications subject to prior authorization; each entry includes the HCPCS/Q-code, medication name, and a 'Click to view' link to the individual prior authorization criteria.
Part B drug index entries
Enumeration of procedure/HCPCS codes mapped to medication names with document links to the drug-specific prior authorization criteria; some entries include an 'effective date (if after 1/1/2026)'.
HCPCS / CPT / Procedure Code Listings
What Providers Must Do / How to Request Authorization
Prior authorization required for listed Part B drugs
Providence Medicare Advantage Plans requires prior authorization for certain Medicare Part B–covered drugs; providers or the prescribing physician must obtain approval before the plan will agree to cover administration of the listed medications. If prior authorization is not obtained in advance, the drug might not be covered by the plan.
Provider contact and support
For questions or assistance with prior authorizations, contact Providence Medicare Advantage Plans at 503-574-8000 or 1-800-603-2340; TTY users should call 711. Phone support is available seven days a week from 8 a.m. to 8 p.m. Pacific Time (note: between April 1 and September 30 the plan is closed Saturdays and Sundays).
Drug‑specific prior authorization links (click to view)
The policy lists individual Part B drugs alongside their HCPCS/Q/CPT procedure codes with 'Click to view' links that lead to the drug‑specific prior authorization criteria for each listed medication.
- Each listed code entry includes a document link labeled 'Click to view' that points to the specific prior authorization criteria.
Effective‑date notes on certain codes
Some entries in the drug index include an effective‑date annotation (displayed as 'if after' dates or specific future dates) indicating the date the prior authorization requirement or listing applies to that procedure code.
- Examples in the list show entries annotated 'if after 1/1/2026' or other dates (e.g., 7/1/2026, 4/1/2026, 6/1/2026).
Index of Part B drugs requiring prior authorization (procedure code → drug → link → effective date)
The document provides an index mapping procedure code(s) to medication name and a document link (Click to view); the third column denotes an effective date when applicable (Procedure Code(s), 1 = Medication Name; 2 = Document Link; 3 = Effective Date if after 1/1/2026).
- Example entries: J9223 = Zepzelca (Lurbinectedin) — Click to view; J3399 = Zolgensma (Onasemnogene abeparvovec‑xioi) — Click to view; J9332 = Vyvgart (Efgartigimod alfa) — Click to view.
- Some index entries include an effective date in column 3 (e.g., Q5159 shows 6/1/2026; C9399/J3590 shows 7/1/2026).
Key Columns, Links, and Definitions
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