Part B PA ST Grid
Part B Prior Authorization & Step Therapy Grids
2023 PA/ST GridPart B Prior Authorization & Step Therapy Forms
*** Please send Forms to the appropriate Fax Numbers ***
| Drug Class | HCPS Codes | Brand / Generic Names | PA Form Link |
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| Adstiladrin | J9029 |
Adstiladrin (nadofaragene firadenovec-vncg) |
Prior Authorization |
| Alpha-1 Proteinase Inhibitors | J0256 |
Prolastin-C (Human) |
Prior Authorization |
| ALS Agents | J1301 |
Radicava (edaravone) |
Prior Authorization |
| Alzheimer's Drugs | J0172 |
Aduhelm (aducanumab-avwa) |
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-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 | 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-Infectives | J0565 |
Zinplava (bezlotoxumab) |
Prior Authorization |
| Anti-Neoplastics: AML | J9203 |
Mylotarg (gemtuzumab ozogamicin) |
Prior Authorization |
| Anti-Neoplastics: B-Cell Lymphoma | J0202, J9039, J9229, J9309, J9359 |
Besponsa (inotuzumab ozogam), Blincyto (blinatumomab), Campath/Lemtrada (alemtuzumab), Polivy (polatuzumab), Zynlonta (loncastuximab tesirine-lpyl) |
Prior Authorization |
| Anti-Neoplastics: Breast Cancer | J9207, J9264, J9306, J9316, J9395 | Abraxane (paclitaxel, protein bound), Faslodex (fulvestrant), Ixempra (ixabepilone), Perjeta (pertuzumab), Phesgo (pertuzumab/ trastuzumab/ hyaluronidase-zzxf) | 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 | J9019, J9021, J9033, J9034, J9266, J9301, J9302 |
Arzerra/Kesimpta (ofatumumab), Bendeka/Treanda (bendamustine HCl) , Erwinaze (asparaginase erwinia chrysanthemi), Gazyva (obinutuzumab), Oncaspar (pegaspargase), Rylaze (asparaginase) |
Prior Authorization |
| Anti-Neoplastics: Lymphoid, Follicular | J9350 |
Lunsumio (mosunetuzumab-axgb) |
Prior Authorization |
| Anti-Neoplastics: Mantle Cell Lymphoma |
J9041 |
Velcade (bortezomib) |
Prior Authorization |
| Anti-Neoplastics: Multiple Myeloma | C9148, J9047, J9144, J9145, J9176, J3399, Q2055 |
Zolgensma (onasemnogene), Darzalex (daratumumab), Empliciti (elotuzumab), Kyprolis (carfilzomib), Abecma (idecabtagene vicieucel) |
Prior Authorization |
| Anti-Neoplastics: NSCLC | J9061, J9173, J9305, J9308 |
Rybrevant (amivantamab-vmjw), Alimta/Pemfexy (pemetrexed), Cyramza (ramucirumab), Imfinzi (durvalumab) |
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 | J9268, J9307, J9315 | 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-Psoriatic: Pustular | J1747 | Spevigo (spesolimab-sbzo) | Prior Authorization |
| Anti-Rheumatic | J0129 |
Orencia (abatacept) |
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 |
| Dopamine Agonists | J0364 | Apokyn / Kynmobi (apomorphine) | Prior Authorization |
| Drugs-Biologics NOC | C9399, J3490, J3590 |
Drugs / Biologics Not Otherwise Classified |
Prior Authorization |
| Elahere | C9146 | Elahere (mirvetuximab soravtansine-gynx) | 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 |
| 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 |
| 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 | J1439, J1443, Q0138, Q0139 | 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 |
| Jemperli | J9272 | Jemperli (dostarlimab-gxly) | Prior Authorization |
| Knee Cartilage Drugs | J7330 | Carticel (Autologous cultured chondrocytes, implant) | Prior Authorization |
| Libtayo | J9119 | Libtayo (cemiplimab-rwlc) | 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 |
| Padcev | J9177 | Padcev (enfortumab vedotin-ejfv) | Prior Authorization |
| Syfovre | J3590 | Syfovre (pegcetacoplan inj) | Prior Authorization |
| Thyroid Eye Disease | J3241 | Tepezza (teprotumumab-trbw) | Prior Authorization |
| Transplant | J0480 | Simulect (basiliximab) | Prior Authorization |
| Trodelvy | J9317 | Trodelvy (sacituzumab govitecan-hziy) | 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 |
| Vyvgart | J9332 | Vyvgart (efgartigimod alfa-fcab) | Prior Authorization |
| Xenpozyme | J0218 | Xenpozyme (olipudase alfa-rpcp) | Prior Authorization |
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Step Therapy |
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| ST: Angioedema | J0596, J0597, J0598, F1290, J1744 |
Ruconet, Berinert, Cinryze (C-1 esterase inhibitor, human), Kalbitor (ecallantide), Firazyr (icatibant acetate) |
Step Therapy Authorization |
| ST: Anti-Psoriatic | J0717, J1602 J2327, J3245, J3357, J3358 |
Cimzia (certolizumab pegol), Ilumya (tildrakizumab), Simponi (Golimumab), Stelara (Ustekinumab; SubQ and IV), Skyrizi (risankizumab-rzaa) |
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, 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) | J2506, Q5108, Q5111, Q5120, Q5122, Q5127, Q5130 |
Neulasta, Fulphila, Udenyca, Stimufend are non-preferred. The preferred products are Nyvepria, Fylnetra, Ziextenzo |
Step Therapy Authorization |
| ST: Colony Stimulating Factors (Short) | J1442, J1447, Q5110, Q5125, Q5101 |
Neupogen, Granix, Nyvestym, Releuko are non-preferred. The preferred product is 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, Q5126, Q5129 |
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), Zirabev (bevacizumab-bvzr), Alymsys (bevacizumab-maly) and Vegzelma (bevacizumab-adcd) (no PA required) |
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: Somatostatic Agents | J1930, J2353 | Somatuline Depot (lanreotide acetate) is non-preferred. The preferred product is Sandostatin (octreotide). | 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 & Synvisc (Hyaluronate Sodium) are non-preferred. The preferred products are Euflexxa, Hyalgan/Supartz & Gel-One (Hyaluronate Sodium). (No PA required) |
Step Therapy Authorization |
| Future Class | Codes | Brand/Generic | Prior Authorization |
2022 PA/ST Grid