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Part B -PA-ST Grid

Part B Prior Authorization & Step Therapy Grids

Part B Prior Authorization & Step Therapy Forms

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Table of Drugs requiring PA
Drug Class HCPS Codes Brand / Generic Names PA Form Link
Adakveo J0791

Adakveo (crizanlizumab-tmca)

Prior Authorization
Adstiladrin J9029

Adstiladrin (nadofaragene firadenovec-vncg)

Prior Authorization
ALS Agents J1301, J1304

Radicava (edaravone), Qalsody (tofersen)

Prior Authorization
Alzheimer's Drugs J0172, J0174

Aduhelm (aducanumab-avwa), Leqembi (lecanemab-irmb)

Prior Authorization
Amyloidosis J0222

Onpattro (patisiran)

Prior Authorization
Analgesics J7336, J2278

Qutenza (capsaicin 8% patch), Prialt (ziconotide)

Prior Authorization
Androgens S0189

TESTOPEL (testosterone pellets)

Prior Authorization
Anemia J0896, J1302

Reblozyl (luspatercept-aamt), Enjaymo (sutimlimab-jome)

Prior Authorization
Anti-Hemophilic: Factor I J7177, J7178 Human Fibrinogen Concentrate & NOS Prior Authorization
Anti-Hemophilic: Factor III J7196, J7197

Antithrombin III (Recombinant), Antithrombin III (Human) 1IU

Prior Authorization
Anti-Hemophilic: Factor IX J7193, J7194, J7195, J7200, J7201, J7202, J7203

FACTOR IX (Non-Recombinant, Complex, Recombinant NOS), Alprolix, Idelvion, Rebinyn, Rixubis

Prior Authorization
Anti-Hemophilic: Factor VII J7189, J7212

FACTOR VII (Recombinant) 1IU NOVOSeven, SEVENFact

 

Prior Authorization
Anti-Hemophilic: Factor VIII J7182, J7185, J7188, J7190, J7191, J7192, J7204, J7205, J2707, J7208, J7209, J7210, J7211 FACTOR VIII (Human, Pegylated-Recombinant), Fusion-Recombinant, Recombinant NOS, (Porcine), Afstyla, Jivi, Kovaltry, Novoeight, Nuwiq, Obizur, Xyntha, Esperoct, Eloctate, Adynovate, Prior Authorization
Anti-Hemophilic: Factor VIII + VWF J7183, J7186, J7187

FACTOR VIII PLUS VWF Complex (Human) 1IU, Humate, Wilate

Prior Authorization
Anti-Hemophilic: Factor X J7175 Factor X (Human) 1IU. Coagadex Prior Authorization
Anti-Hemophilic: Factor XIII J7180, J7181

FACTOR XIII (Human), FACTOR XIII (Recombinant)

Prior Authorization
Anti-Neoplastics: B-Cell Lymphoma J0202, J9039, J9229, J9286, J9309, J9321, J9359, Q2041

Besponsa (inotuzumab ozogam), Blincyto (blinatumomab), Campath/Lemtrada (alemtuzumab), Columvi (glofitamab-gxbm), Epkinly (epocoritamab-bysp), Polivy (polatuzumab), Zynlonta (loncastuximab tesirine-lpyl), Yescarta (axicabtagene ciloleucel)

Prior Authorization
Anti-Neoplastics: Breast Cancer J9207, J9258, J9264, J9306, J9316, J9395 Abraxane (paclitaxel, protein bound), Faslodex (fulvestrant), Ixempra (ixabepilone), Perjeta (pertuzumab), Phesgo (pertuzumab/ trastuzumab/ hyaluronidase-zzxf), Teva-Brand (paclitaxel, protein-bound) Prior Authorization
Anti-Neoplastics: Colorectal J9400, J9055, J9303

Zaltrap (ziv-aflibercept), Erbitux (cetuximab), Vectibix (panitumumab)

Prior Authorization
Anti-Neoplastics: Liposarcoma J9179, J9352

Halaven (eribulin mesylate), Yondelis (trabectedin)

Prior Authorization
Anti-Neoplastics: Lymphoid J9019, J9020, J9021, J9033, J9034, J9036, J9118, J9262, J9266, J9301, J9302

Arzerra/Kesimpta (ofatumumab), Bendeka/Treanda/Belrapzo (bendamustine HCl), Erwinaze (asparaginase erwinia chrysanthemi), Gazyva (obinutuzumab), Oncaspar (pegaspargase), Rylaze (asparaginase), Asparlas (calaspargase pegol-mknl), Synribo (omacetaxine mepesuccinate)

Prior Authorization
Anti-Neoplastics: Lymphoid, Follicular J9057

Aliqopa (copanlisib)

Prior Authorization
Anti-Neoplastics: Melanoma J9015, J9274, J9298, J9325

Proleukin (aldesleukin), Kimmtrak (tebentafusp-tebn), Opdualag (nivolumab/relatilmab-rmbw), Imlygic (talimogene laherparepvec)

Prior Authorization
Anti-Neoplastics: Multiple Myeloma J9047, J9144, J9145, J9176, J9227, J3399, Q2055, Q2056

Zolgensma (onasemnogene), Darzalex (daratumumab), Darzalex Faspro (daratumumab/ hyaluronidase-fihj), Empliciti (elotuzumab), Kyprolis (carfilzomib), Sarclisa (isatuximab-irfc), Abecma (idecabtagene vicieucel), Carvykti (ciltacabtagene autoleucel)

Prior Authorization
Anti-Neoplastics: Prostate Cancer J9043, J9155, Q2043 Degarelix (degarelix acetate), Jevtana (Cabazitaxel), Provenge (sipuleucel-T) Prior Authorization
Anti-Neoplastics: Renal J9023, J9330 Bavencio (avelumab), Torisel (temsirolimus) Prior Authorization
Anti-Neoplastics: T-Cell / Hairy Lymphoma J9042, J9160, J9268, J9307, J9315, J9318, J9319 Adcetris (brentuximab vedotin),  Romidepsin (generic), Folotyn (pralatrexate inj), Istodax (romidepsin), Nipent (pentostatin), Lymphir (denileukin diftitox) Prior Authorization
Anti-Neoplastics: Opdivo J9299 Opdivo (nivolumab) Prior Authorization
Anti-Neoplastics: Tecentriq J9022 Tecentriq (atezolizumab) Prior Authorization
Anti-Neoplastics: Valstar J9357 Valstar (valrubicin) Prior Authorization
Anti-Neoplastics: Yervoy J9228 Yervoy (ipilimumab) Prior Authorization
Anti-Rheumatic J0129

Orencia (abatacept)

Prior Authorization
Arcalyst 2793

Arcalyst (rilonacept)

Prior Authorization
Asthma: Non-Specific J2356

Tezspire (tezepelumab-ekko)

Prior Authorization
Brineura J0567

Brineura (cerliponase alfa)

Prior Authorization
Castleman's Disease J2860 Sylvant (siltuximab) Prior Authorization
Chemotherapy NOC J9999

Chemotherapy Not Otherwise Classified Agents

Prior Authorization
Coagulants / Hemophilia J1411, J7170, J7198

Hemgenix (etranacogene dezaparvovec-drlb), Hemlibra (emicizumab-kxwh), AICC

Prior Authorization
Coagulants / Hemophilia NOC J7199 Hemophilia/Clotting Factor Not Otherwise Classified Prior Authorization
Colony Stimulating Factors (Leukine) J2820

Leukine (sargramostim)

Prior Authorization
Covid 19 Drugs J0248, Q0222

Veklury (remdesivir), bebtelovimab

Prior Authorization
Danyelza J9348

Danyelza (naxitamab-gqgk)

Prior Authorization
Dopamine Agonists J0364 Apokyn / Kynmobi (apomorphine) Prior Authorization
Drugs-Biologics NOC C9399, J3490, J3590

Drugs / Biologics Not Otherwise Classified

Prior Authorization
Duchenne Muscular Dystrophy J1413, J1426, J1427, J1428, J1429 Amondys (casimersen), Viltepso (viltolarsen), Exondys (eteplirsen), Vyondys (golodirsen) Prior Authorization
Elahere C9146 Elahere (mirvetuximab soravtansine-gynx), Elevidys (delandistrogene moxeparvovec-rokl), Prior Authorization
Elzonris J9269 Elzonris (tagraxofusp-erzs) Prior Authorization
Enzymes and Enzymatics J0180, J0221, J0257, J0775, J1322, J1458, J1786, J1931, J2783, J3060, J3385, Aldurazyme (laronidase), Vimizim (elosulfase alfa), Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), VPRIV (velaglucerase), Elitek (rasburicase), Fabrazyme (agalsidase), Glassia (alpha 1 proteinase inhibitor), Lumizyme / Myozyme (alglucosidase alfa), Naglazyme (galsulfase), Xiaflex (collagenase, clostridium histolyticum) Prior Authorization
Fabry's Disease J1413 Elfabrio (pegunigalsidase alfa-iwxj) Prior Authorization
Fyarro J9331 Fyarro (sirolimus protein-bound) Prior Authorization
Gamifant J9210 Gamifant (emapalumab-lzsg) Prior Authorization
Geographic Atrophy J2781, J3490 Syfovre (pegcetacoplan), Izervay (avacincaptad pegol) Prior Authorization
GI Biologic J3380 Entyvio (vedolizumab) Prior Authorization
Givosiran J0223 Givosiran injection Prior Authorization
Gonadotropin J1675, J9225, J9226 Supprelin LA (implant), Vantas (implant) [histrelin acetate] Prior Authorization
Gout J2507 Krystexxa (Pegloticase) Prior Authorization
Graves Disease J3241 TEPEZZA (teprotumumab-trbw) Prior Authorization
Growth Hormone Antagonist J2170, J2502 Increlex (mecasermin), Signifor LAR (pasireotide) Prior Authorization
Hematological J2562, J2796 Mozobil (plerixafor), Nplate (romiplostim) Prior Authorization
Ilaris J0638 Ilaris (canakinumab) Prior Authorization
Immune Globulins J7504, J7511 Atgam (antithymocyte globulin equine), Thymoglobulin (antithymocyte globulin rabbit) Prior Authorization
Immune Modulators J2323 Tysabri (natalizumab) Prior Authorization
Immunosuppressives NOC J7599 Immunosuppressive Drugs Not Otherwise Classified Prior Authorization
IVIG: Hep B J1571, J1573 Hepagam B [IM], Hepatitis B immune globulin [IV] Prior Authorization
Jemperli J9272 Jemperli (dostarlimab-gxly) Prior Authorization
Jelmyto J9281 Jelmyto (mitomycin pyelocalyceal instillation) Prior Authorization
Jetrea J7316 Jetrea (ocriplasmin) Prior Authorization
Kanuma J2840 Kanuma (sebelipase alfa) Prior Authorization
Knee Cartilage Drugs J7330 Carticel (Autologous cultured chondrocytes, implant) Prior Authorization
Lamzede J0217 Lamzede (velmanase alfa-tycv) Prior Authorization
Lartuvo J9285 Lartuvo (olaratumab) Prior Authorization
Libtayo J9119 Libtayo (cemiplimab-rwlc) Prior Authorization
Lutetium A9513, A9607 Lutathera (lutetium lu 177 dotatate), Pluvicto lutetium lu 177 vipivotide tetraxetan) Prior Authorization
Mepsevii J3397 Mepsevii (vestronidase alfa-vjbk) Prior Authorization
Metabolic Drugs J1743 Eleprase (idursulfase) Prior Authorization
Mineral Deficiency J0584, J0606, J0630 Crysvita (burosumab-twza), Parsabiv (etelcalcetide), Miacalcin (calcitonin salmon) Prior Authorization
Mitosol J7315 Mitosol (mitomycin, ophthalmic) Prior Authorization
Myasthenia Gravis J9332, J9333 Vyvgart (efgartigimod alfa-fcab), Rystiggo (rozanolixizumab-noli) Prior Authorization
Neuro-Muscular Blockers J0585, J0586, J0587, J0588

Botox (onabotulinumtoxin), Dysport (abobotulinumtoxin A), Myobloc (rimabotulinumtoxin B), Xeomin (incobotulinumtoxin A)

Prior Authorization
NMOSD J1823 Uplizna (inebilizumab-cdon) Prior Authorization
Ophthalmic Implants J7311, J7312 Retisert (fluocinolone acetonide), Ozurdex (dexamethasone) Prior Authorization
Ophthalmic Other J3396 Visudyne (verteporfin inj) Prior Authorization
Opioid Agonists J0570, J0592, Q9991, Q9992 Probuphine (buprenorphine implant), Buprenex (buprenorphine), Sublocade (buprenorphine XR) Prior Authorization
Oxlumo J0224 Oxlumo (lumasiran) Prior Authorization
Padcev J9177 Padcev (enfortumab vedotin-ejfv) Prior Authorization
Pancreatic Cancer J9205 Onivyde (irinotecan lipsome) Prior Authorization
Pompe Disease J0219, J0220 Nexviazyme (avalglucosidase alfa-ngpt), Lumizyme (alglucosidase alfa) Prior Authorization
Poteligeo J9204 Poteligeo (mogamulizumab-kpkc) Prior Authorization
Roctavian J1412 Roctavian (valoctocogene roxaparvovec-rvox) Prior Authorization
Ryplazim J2998 Ryplazim (plasminogen, human-tvmh) Prior Authorization
Scenesse J7352 Scenesse (afamelanotide implant) Prior Authorization
Somatropin Products J2941 Somatropin (Humatropin, etc) Prior Authorization
Spinraza J2326 Spinraza (nusinersen) Prior Authorization
Thyroid Eye Disease J3241 Tepezza (teprotumumab-trbw) Prior Authorization
Tivdak J9273 Tivdak (tisotumab vedotin-tftv) Prior Authorization
Transplant J0480, J0485 Simulect (basiliximab), Nulojix (belatacept) Prior Authorization
Trodelvy J9317 Trodelvy (sacituzumab govitecan-hziy) Prior Authorization
Unituxin J1246 Unituxin (dinutuximab) Prior Authorization
Vonvendi J7179 Vonvendi (Von Willebrand Factor, Recombinant) Prior Authorization
Vyepti J3032 Vyepti (eptinezumab-jjmr) Prior Authorization
Vyjuvek J3401 Vyjuvek (beremagene geperpavec-svdt) Prior Authorization
Xenpozyme J0218 Xenpozyme (olipudase alfa-rpcp) Prior Authorization
Zepzelca J9223 Zepzelca (lurbinectedin) Prior Authorization

Step Therapy

 

ST: Actemra J3262

Actemra (tocilizumab)

Step Therapy Authorization
ST: Alpha-1 Proteinase Inhibitors J0256

Prolastin-C (Human)

Step Therapy  Authorization
ST: Angioedema J0593, J0596, J0597, J0598, J0599, J1290, J1744

Takhzyro (lanadelumab-flyo), Berinert / Cinryze / Ruconest / Haegarda (C-1 esterase inhibitor, human), Kalbitor (ecallantide), (Firazyr (icatibant acetate)

Step Therapy Authorization
ST: Anti-Emetic J1454

Akynzeo (fosnetupitant-palonosetron)

Step Therapy Authorization
ST: Anti-Inflammatory J0717, J1747, J2327, J3245, J1602, J3357, J3358

Cimzia (certolizumab pegol), Spevigo (spesolimab-sbzo), Skyrizi (risankizumab-rzaa), Ilumya (tildrakizumab), Simponi (Golimumab), Stelara (Ustekinumab; SubQ and IV)

Step Therapy Authorization
ST: Anti-Neoplastic: AML J9203, J9025

Mylotarg (gemtuzumab ozogamicin), Vidaza (azacitidine)

Step Therapy Authorization
ST: Anti-Neoplastic: Mantle Cell Lymphoma J9046, J9048, J9049, J9041

Bortezomib Products: Dr. Reddy’s, Fresenia, Hospira, bortezomib (velcade)

Step Therapy Authorization
ST: Anti-Neoplastic: NSCLC J1448, J9061, J9305, J9308, J9173

(Cosela (Trilaciclib), Rybrevant (amivantamab-vmjw), Portrazza (necitumumab), Cyramza (ramucirumab), Imfinzi (durvalumab) are non-preferred. The preferred products are pemetrexed biosimilars (NON-Pemfexy)

Step Therapy Authorization
ST: Anti-Neoplastics: Keytruda J9271 Keytruda (pembrolizumab) Step Therapy Authorization
ST: Anti-Neoplastic: Pemetrexed J9304, J9294, J9296, J9297, J9305, J9314

Pemfexy, Hospira, Accord, Sandz, Alimta, Teva

Step Therapy Authorization
ST: Asthma J0517, J2182, J2357, J2786,

Fasenra (benralizumab), Cinqair (reslizumab), Nucala (mepolizumab), Xolair (omalizumab)

Step Therapy Authorization
ST: Bone Resorption Inhibitors J0897, J3490, J3111, J2430, J3489 Prolia/Xgeva (denosumab), Tymlos and Evenity (romosozumab-aqqg) are non-preferred. The preferred products are pamidronate and zoledronic acid (no PA required) Step Therapy Authorization
ST: Clostridium difficile (C-diff) J1440, J0565 Rebyota (fecal microbiota, live-jslm), Zinplava (bezlotoxumab) - (No PA required for most preferred Part D alts) Step Therapy Authorization
ST: Colony Stimulating Factors (Long) J2505, J2506, Q5108, Q5111, Q5120, Q5122, Q5127, Q5130

Neulasta, Fulphila, Udenyca, Nyvepria, Stimufend are non-preferred. The preferred products are Neulasta (ex bio), Fylnetra, Ziextenzo

Step Therapy Authorization
ST: Colony Stimulating Factors (Short) J1442, J1447, J1449, Q5110, Q5125, Q5101

Neupogen (filgrastim), Granix (tbo-filgrastim), Rolvedon (eflapregrastim-xnst), Nyvestym (filgrastim-aafi), Releuko (filgrastim-ayow) are non preferred. The preferred product is Zarxio (filgrastim-sndz)

Step Therapy Authorization
ST: Complement Inhibitor J1300, J1303 Soliris (eculizumab) is non-preferred. The preferred product is Ultomiris (ravulizumab-cwvz) (Requires Prior Authorization) Step Therapy Authorization
ST: Dyslipidemia J1306 Leqvio (inclisiran) is non-preferred. Preferred products are Part D PCSK9 inhibitors (Praluent, Repatha, No PA required) Step Therapy Authorization
ST: Erythropoiesis Stimulating Agents J0881, J0882, J0885, J0886, J0887, J0888, Q4081, Q5105, Q5106 Aranesp (darbepoetin alfa) Epogen (epoetin alfa), and Procrit (epoetin alfa) are non-preferred. The preferred product is Retacrit (epoetin alpha-epbx), Mircera (epoetin beta), Epogen (biosimilar-epoetin alfa) Step Therapy Authorization
ST: HIV Therapies J1961 Sunlenca (lenacapavir) is non-preferred. The preferred products are Part D HIV products (no PA required) Step Therapy Authorization
ST: Humira J0135 Humira (adalimumab) Step Therapy Authorization
ST: Infliximab J1745, Q5103, Q5104, Q5121 Remicade (infliximab), Renflexis (infliximab-abda), Avsola (infliximab-axxq) are non-preferred. The preferred product is Inflectra (infliximab-dyyb) Step Therapy Authorization
ST: Iron Salts J1437, Q0138, Q0139, J1439, J1443, J1750, J1756, J2916 Monoferiric (derisomaltose), Feraheme (ferumoxytol), Injectafer (ferric carboxymaltose), Triferic (ferric pyrophosphate) are Non-preferred products. The preferred products are: Infed (iron dextran), Venofer (iron sucrose), Ferrlecit (sodium ferric gluconate cmplx)(No PA required) Step Therapy Authorization
ST: IVIG J1459, J1460, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1562, J1566, J1568, J1569, J1572, J1575, J1599

Asceniv [non-lyophilized], Bivigam, Cuvitru, Flebogamma, Gammagard, Gammaplex, Hizentra, HyQvia, IVIG liquid, IVIG powder, Xembify, are non-preferred. The preferred products are Gamunex, Octagam and Privigen

Step Therapy Authorization
ST: Lupus J0491, J0490

Saphnelo (anifrolumab-fnia) is non-preferred. The preferred product is Benlysta (belimumab)

Step Therapy Authorization
ST: Multiple Sclerosis J1595, J2329, J2350, J7513

Ocrevus (ocrelizumab), Copaxone (Glatiramer acetate), Zenapax (daclizumab), Briumvi (ublituximab) are Non-preferred. The preferred products are Part D alternatives including Aubagio and generic glatiramer (no PA required for most preferred Part D alts).

Step Therapy Authorization
ST: Ophthalmic (VEGF) Inhibitors

J0178, J0179, J2503, J2777, J2778, J2779, J9035, Q5107, Q5118, Q5124, Q5126, Q5128, Q5129,J3590

Eylea (Aflibercept 2mg), Eylea HD (Aflibercept 8mg), Lucentis (Ranibizumab), Macugen (Pegaptanib), Beovu (Brolucizumab-dbll), Susvimo (ranibizumab), Vabysmo (faricimab-svoa), Byooviz (ranibizumab-nuna) are non-preferred. The preferred products are Intraocular: Avastin (Bevacizumab), Mvasi (Bevacizumab-awwb), Zirabev (bevacizumab-bvzr), Alymsys (bevacizumab-maly), Alymsys (bevacizumab-maly) and Vegzelma (bevacizumab-adcd) (no PA required)

Step Therapy Authorization
ST: Parkinson's Disease J7340 Duopa is the non-preferred product. preferred products are Part D carbidopa/levodopa alternatives. Step Therapy Authorization
ST: Pulmonary Arterial Hypertension J1325, J3285, J7686, Q4074 Tyvaso / Remodulin (treprostinil), Ventavis (iloprost), Flolan / Veletri (epoprostenol sodium) Step Therapy Authorization
ST: Rituximab J9311, J9312, Q5115, Q5119, Q5123 Rituxan (rituximab) IV, Rituxan Hycela (rituximab/hyaluronidase human) and Truxima (rituximab-abbs) IV are non-preferred. The preferred products are, Ruxience (rituximab-pvvr) and Riabni (rituximab-arrx) Step Therapy Authorization
ST: Somatostatin Agents J1930, J1932, J2353, J2354 Somatuline Depot (lanreotide acetate), Cipla (lanreotide), Sandostatin LAR (octreotide depot) are non-preferred. The preferred product is Sandostatin (octreotide non-depot). Step Therapy Authorization
ST: Trastuzumab J9354, J9355, J9356, J9358, Q5112, Q5113, Q5114, Q5116, Q5117

Kadcyla (ado-trastuzumab emt), Herceptin (trastuzumab) IV and Herceptin Hylecta (trastuzumab/hyaluronidase-oysk), Enhertu (fam-trastuzumab deruxtecan-nxki) are non-preferred. The preferred products are: Ontruzant (trastuzumab-dttb), Herzuma (trastuzumab-pkrb), Trazimera (trastuzumab-qyyp), Kanjinti (trastuzumab-anns), Ogivri (trastuzumab-dkst)

Step Therapy Authorization
ST: Viscosupplements J7321, J7323, J7324, J7325, J7326, J7327

Orthovisc, Monovisc are non-preferred. The preferred products are Synvisc [One], Euflexxa, Hyalgan/Supartz & Gel-One (Hyaluronate Sodium). (No PA required)

Step Therapy Authorization
Future Class Codes Brand/Generic Prior Authorization