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Requirements for Medicare Part B drugs

Under Medicare Advantage plans, some medically administered Part B drugs, like injectables or biologics, may have special requirements or coverage limits. This is called utilization management. We’ll help you find the information you need.

 

Coverage criteria lookup

Helping you find Part B drug coverage

Precertification lists

 

Some Part B drugs require prior approval before they can be administered. This is called precertification or prior authorization. This helps us review a drug to ensure it’s safe and appropriate for your patient. Our medical precertification lists feature the latest information, including Part B drugs.

 

Find precertification lists

 

Find detailed Part B drug coverage criteria below.

 

Step therapy overview

Step therapy overview

Another type of utilization management is step therapy. This is where we require a trial of a preferred drug to treat a medical condition before covering another non-preferred drug. 

Here’s an example:

Drug A and drug B both treat a medical condition. However, we may prefer drug A and require a trial of it first if your patient is new to the therapy. If drug A doesn’t work, we’ll cover drug B. The preferred drug should be used first.  

Step therapy doesn’t apply to patients who’ve already received treatment with the non-preferred drug within the past 365 days. During the review, you can also share reasons that the preferred drugs may not be medically appropriate for your patient’s unique medical needs.

For more information:


To find a complete list of drugs and categories subject to step therapy, review the “Preferred drugs” tab. You can also find detailed Part B drug step therapy criteria below.

Preferred drug lists

Preferred drug lists

Coverage criteria lookup

 

This tool helps you find Part B drugs with utilization management requirements. Select a drug to find its HCPCS code(s), coverage criteria documents, step therapy documents and fax forms, if appilcable. 

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Notes

 

*FOR DRUG COVERAGE DETAILS: Universal Medicare coverage criteria will be used for this drug.

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.

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