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Part B -PA-ST Grid

Part B Prior Authorization & Step Therapy Grids

2023 PA/ST Grid

Part B Prior Authorization & Step Therapy Forms

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*** Please send Forms to the appropriate Fax Numbers ***

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

Alzheimer's Drugs J0172

Aduhelm (aducanumab-avwa)

Prior Authorization
Alpha-1 Proteinase Inhibitors J0256

Prolastin-C (Human)

Prior Authorization
ALS Agents J1301

Radicava (edaravone)

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

Reblozyl (luspatercept-aamt)

Prior Authorization
Angioedema J0596, J0597, J0598, J1290, J1744

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

Prior Authorization
Anti-Emetic J1454

Akynzeo (fosnetupitant-palonosetron)

Prior Authorization
Anti-Infectives J0565

Zinplava (bezlotoxumab)

Prior Authorization
Anti-Neoplastics: AML J9203

Mylotarg (gemtuzumab ozogamicin)

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

Besponsa (inotuzumab ozogam), Blincyto (blinatumomab), Campath/Lemtrada (alemtuzumab), Polivy (polatuzumab), Zynlonta (loncastuximab tesirine-lpyl)

Prior Authorization
Anti-Neoplastics: Breast Cancer J9264, J9395, J9207, J9306 Abraxane (paclitaxel, protein bound), Faslodex (fulvestrant), Ixempra (ixabepilone), Perjeta (pertuzumab) Prior Authorization
Anti-Neoplastics: Colorectal J9055, J9303

Erbitux (cetuximab), Vectibix (panitumumab)

Prior Authorization
Anti-Neoplastics: Liposarcoma J9179, J9352

Halaven (eribulin mesylate), Yondelis (trabectedin)

Prior Authorization
Anti-Neoplastics: Lymphoid J9302, J9033, J9034, J9019, J9301, J9266, J9021

Arzerra/Kesimpta (ofatumumab), Bendeka/Treanda (bendamustine HCl) , Erwinaze (asparaginase erwinia chrysanthemi), Gazyva (obinutuzumab), Oncaspar (pegaspargase), Rylaze (asparaginase)

Prior Authorization
Anti-Neoplastics: Mantle Cell Lymphoma

J9041

Velcade (bortezomib)

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

Zolgensma (onasemnogene), Darzalex (daratumumab), Empliciti (elotuzumab), Kyprolis (carfilzomib), Abecma (idecabtagene vicieucel)

Prior Authorization
Anti-Neoplastics: NSCLC J9061, J9305, J9308, J9173

Rybrevant (amivantamab-vmjw), Alimta/Pemfexy (pemetrexed), Cyramza (ramucirumab), Imfinzi (durvalumab)

Prior Authorization
Anti-Neoplastics: Prostate Cancer J9155, J9043, 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 J9307, J9315, J9268 Folotyn (pralatrexate inj), Istodax (romidepsin), Nipent (pentostatin) Prior Authorization
Anti-Neoplastics: Adcetris J9042 Adcetris (brentuximab vedotin) Prior Authorization
Anti-Neoplastics: Keytruda J9271 Keytruda (pembrolizumab) 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
Chemotherapy NOC J9999

Chemotherapy Not Otherwise Classified Agents

Prior Authorization
Coagulant-Hemophilia A J7170, J7198

Hemlibra (emicizumab-kxwh), AICC

Prior Authorization
Colony Stimulating Factors (Leukine) J2820

Leukine (sargramostim)

Prior Authorization
Covid 19 Drugs J0248, Q0222

Veklury (remdesivir), bebtelovimab

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

Drugs / Biologics Not Otherwise Classified

Prior Authorization
Enzymes and Enzymatics J0221, J0257, J0775, J1322, J0180, J1786, J1931, J2783, J3385, J3060, J1458 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
Anti-Hemophilic: Factor I J7178 Human Fibrinogen Concentrate 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

FACTOR VII (Recombinant) 1IU

Prior Authorization
Anti-Hemophilic: Factor VIII J7182, J7185, J7188, J7190, J7191, J7192, J7205, J2707, J7208, J7209, J7210, J7211 FACTOR VIII (Human, Pegylated-Recombinant, Fusion-Recombinant, Recombinant NOS, Porcine), Afstyla, Jivi, Kovaltry, Novoeight, Nuwiq, Obizur, Xyntha Prior Authorization
Anti-Hemophilic: Factor VIII + VWF J7186, J7183, 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
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
Growth Hormone Antagonist J2502 Signifor LAR (pasireotide) Prior Authorization
Hematological J2562, J2796 Mozobil (plerixafor), Nplate (romiplostim) Prior Authorization
Hemophilia-Clotting Factor Drugs NOC J7199 Hemophilia/Clotting Factor Not Otherwise Classified 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
Immunologics J0485, J0490, J3262 Actemra (tocilizumab), Benlysta (belimumab), Nulojix (belatacept) Prior Authorization
Iron Salts Q0138, Q0139, J1439, J1443 Feraheme (ferumoxytol), Injectafer (ferric carboxymaltose), Triferic (ferric pyrophosphate) Prior Authorization
IVIG: Hep B J1571, J1573 Hepagam B [IM], Hepatitis B immune globulin [IV] Prior Authorization
Knee Cartilage Drugs J7330 Carticel (Autologous cultured chondrocytes, implant) Prior Authorization
Metabolic Drugs J1743 Eleprase (idursulfase) Prior Authorization
Mineral Deficiency J0584 Crysvita (burosumab-twza) Prior Authorization
Multiple Sclerosis J2350 Ocrevus (ocrelizumab) Prior Authorization
Neuro-Muscular Blockers J0585, J0586, J0587, J0588

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

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
Somatostatic Agents J1930 Somatuline Depot (lanreotide acetate) Prior Authorization
Somatostatin Analogs J2353 Sandostatin (octreotide) Prior Authorization
Castleman's Disease J2860 Sylvant (siltuximab) Prior Authorization
Thyroid Eye Disease J3241 Tepezza (teprotumumab-trbw) Prior Authorization
Transplant J0480 Simulect (basiliximab) Prior Authorization
Vitreomacular Adhesion J7316 Jetrea (ocriplasmin) Prior Authorization
Vonvendi J7179 Vonvendi (Von Willebrand Factor, Recombinant) Prior Authorization
Vyepti J3032 Vyepti (eptinezumab-jjmr) Prior Authorization


Step Therapy

ST: Anti-Psoriatic J0717, J3245, J3357, J3358, J1602

Cimzia (certolizumab pegol), Ilumya (tildrakizumab), Simponi (Golimumab), Stelara (Ustekinumab; SubQ and IV)

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

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

Step Therapy Authorization
ST: Bone Resorption Inhibitors J0897, J3111, J2430, J3489 Prolia/Xgeva (denosumab) and Evenity (romosozumab-aqqg) are non-preferred. The preferred products are pamidronate and zoledronic acid (no PA required) Step Therapy Authorization
ST: Colony Stimulating Factors (Long) J2505, J2506, Q5108, Q5111, Q5120, Q5122

Neulasta, Fulphila, Udenyca, Nyvepria are non-preferred. The preferred products are Neulasta, Ziextenzo

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

Neupogen, Granix, Nyvestym, Releuko are non-preferred. The preferred products are Zarxio

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: 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: Infliximab J1745, Q5103, Q5121 Remicade (infliximab) and Inflectra (infliximab-dyyb) are non-preferred. The preferred product is Avsola (infliximab-axxq) Step Therapy Authorization
ST: IVIG J1459, J1460, J1554, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1562, J1566, J1568, J1569, J1571, 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: Ophthalmic (VEGF) Inhibitors J0178, J0179, J2503, J2777, J2778, J2779, J9035, Q5107, Q5118, Q5124

Eylea (Aflibercep), 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) and Zirabev (bevacizumab-bvzr)

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 J9310, J9311, J9312, Q5115, Q5119, Q5123 Rituxan (rituximab) IV and Rituxan Hycela (rituximab/hyaluronidase human) is non-preferred. The preferred products are Truxima (rituximab-abbs) IV, Ruxience (rituximab-pvvr), Riabni (rituximab-arrx) Step Therapy Authorization
ST: Trastuzumab J9354, J9355, J9356, Q5112, Q5113, Q5116, Q5117

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

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

Euflexxa, Monovisc & Synvisc (Hyaluronate Sodium) are non-preferred. The preferred products are Hyalgan, Orthovisc & Supartz (Hyaluronate Sodium)

Step Therapy Authorization
Future Class Codes Brand/Generic Prior Authorization

2022 PA/ST Grid