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Medicare Part B Drugs


Clinic-Administered Medications Requiring Prior Authorization


Monthly updates may be added to the Prior Authorization List. Providers are reminded to review the Prior Authorization list on a regular basis for any updates or changes which may be added.

Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Prior authorization is required for the clinic-administered medications listed below. Practitioners must submit a prior authorization request via My Quartz Tools or fax us a Clinic-Administered Medication PA Form.

  • Abatacept (Orencia) infusion
  • Afamelanotide acetate (Scenesse)
  • Agalsidase beta (Fabrazyme)
  • Alemtuzumab (Lemtrada)
  • Alglucosidase Alfa (Lumizyme, Myozyme)
  • Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
  • Artesunate
  • Atezolizumab (Tecentriq)
  • Avelumab (Bavencio)
  • Belantamab (Blenrep)
  • Belimumab (Benlysta) infusion
  • Benralizumab (Fasenra)
  • Bevacizumab (Avastin Brand) - No PA required if intravitreal injection. Biosimilar(s) covered without PA.
  • Bezlotoxumab (Zinplava)
  • Brexanolone (Zulresso)
  • Burosumab (Crysvita)
  • C1 esterase inhibitor (Berinert)
  • C1 esterase inhibitor (Cinryze)
  • C1 esterase inhibitor (Ruconest)
  • Calaspargase (Asparlas)
  • Canakinumab (Ilaris)
  • Caplacizumab (Cablivi)
  • Carfilzomib (Kyprolis)
  • Casimersen (Amondys 45)
  • Cemiplimab (Libtayo)
  • Cerliponase Alfa (Brineura)
  • Certolizumab (Cimzia)
  • Crizanlizumab (Adakveo)
  • Crizanlizumab-tmca (Adakveo)
  • Daratumumab (Darzalex)
  • Daratumumab and hyaluronidase (Darzalex Faspro)
  • Deoxycholic acid (Kybella)
  • Dostarlimab (Jemperli)
  • Durvalumab (Imfinzi)
  • Ecallantide (Kalbitor)
  • Edaravone (Radicava)
  • Elapegademase (Revcovi)
  • Elotuzumab (Empliciti)
  • Emapalumab (Gamifant)
  • Emicizumab (Hemlibra)
  • Enfortumab vedotin (Padcev)
  • Epoetin Alfa (Epogen Brand) - Biosimilar(s) covered without PA.
  • Epoetin Alfa (Procrit Brand) - Biosimilar(s) covered without PA.
  • Eptinezumab (Vyepti)
  • Esketamine (Spravato)
  • Evinacumab (Evkeeza)
  • Givosiran (Givlaari)
  • Golimumab IV (Simponi)
  • Golodirsen (Vyvondys 53)
  • Guselkumab (Tremfya)
  • Human Chorionic Gonadotropin (HCG) (Novarel, Pregnyl)
  • Hydroxyprogesterone caproate (Makena)
  • Inebilzumab (Uplizna)
  • Infliximab (Remicade brand) - Biosimilar(s) covered without PA.
  • Inotersen (Tegsedi)
  • Interferon alfa N3 (Alferon N)
  • Interferon alfa-2b (Intron A)
  • Interferon beta-1a (Avonex, Rebif)
  • Iobenguane iodine (Azedra)
  • Ipilimumab (Yervoy) 
  • Isatuximab (Sarclisa)
  • Letermovir (Prevymis)
  • Loncastuximab Tesirine (Zynlonta)
  • Lumasiran (Oxlumo)
  • Lurbinectedin (Zepzelca)
  • Luspatercept (Reblozyl)
  • Lutetium Lu 177 dotatate (Lutathera)
  • Margetuximab (Margenza)
  • Melphalan Flufenamide (Pepaxto)
  • Mepolizumab (Nucala)
  • Mogamulizumab (Poteligeo)
  • Moxetumomab pasudotox (Lumoxiti)
  • Natalizumab (Tysabri)
  • Naxitamab (Danyelza)
  • Necitumumab (Portrazza)
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • onasemnogene abeparvovec (Zolgensma)
  • Palifermin (Kepivance)
  • Palivizumab (Synagis)
  • Patisiran (Onpattro)
  • Pegcetacoplan (Empaveli)
  • Pegfilgrastim (Neulasta Brand) - Biosimilar(s) covered without PA.
  • Pegloticase (Krystexxa)
  • Pembrolizumab (Keytruda)
  • Polatuzumab vedotin (Polivy)
  • Ramucirumab (Cyramza)
  • Ravulizumab (Ultomiris)
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rituximab (Rituxan Brand) - Biosimilar(s) covered without PA.
  • Romiplostim (Nplate)
  • Romosozumab (Evenity)
  • Sacituzumab (Trodelvy)
  • Sebelipase Alfa (Kanuma)
  • Siltuximab (Sylvant)
  • Tafasitamab (Monjuvi)
  • Tagraxofusp (Elzonris)
  • Teprotumumab (Tepezza)
  • Testosterone Pellet 75 MG
  • Testosterone Subcutaneous Hormone Pellet Implantation
  • Testosterone Undecanoate (Aveed)
  • Tildrakizumab (Ilumya)
  • Tocilizumab (Actemra)
  • Trabectedin (Yondelis)
  • Trastuzumab (Herceptin Brand) - Biosimilar(s) covered without PA.
  • Trilaciclib (Cosela)
  • Unclassified drugs or biologics (only if >$2500)
  • Ustekinumab (Stelara IV)
  • Vedolizumab (Entyvio)
  • Viltolarsen (Viltepso)
  • Voretigene neparvovec (Luxturna)
  • Xofigo (Radium 223 Dichloride)

Medicare Drug Coverage Policies apply (but do not require prior authorization):
(for the most up-to-date Medicare policies and coverage, search the
Medicare Coverage Database)

  • Abarelix (Plenaxis) for the Treatment of Prostate Cancer (NCD 110.19)
  • Aflibercept (Eylea) (L33394)
  • Bevacizumab and biosimilars (L33394)
  • Bortezomib (Velcade) (L33394)
  • Botulinum toxins: AbobotulinumtoxinA (Dysport), IncobotulinumtoxinA (Xeomin), OnabotulinumtoxinA (Botox), RimabotulinumtoxinB (Myobloc) (L33394)
  • Brolucizumab (Beovu) (L33394)
  • CAR T Therapies: Axicabtagene Ciloleucel (Yescarta), Brexucabtagene Autoleucel (Tecartus), Idecabtagene Vicleucel (Abecma), Lisocabtagene Maraleucel (Breyanzi), Tisagenlecleucel (Kymriah) (NCD 110.24)
  • Denosumab (Prolia, Xgeva) (L33394)
  • Eculizumab (Soliris) (L33394)
  • Erythropoiesis Agents in Cancer and Related Neoplastic Conditions (NCD 110.21)
  • External Infusion Pumps (and associated drugs) (L33794)
  • Filgrastim biosimilars (L33394)
  • Hyaluronans (Intra-articular injections) (L33394)
  • Ibandronate (Boniva) (L33394)
  • Intravenous Immune Globulin (IVIG) (L33394)
  • Intravenous Iron Therapy (NCD 110.10)
  • Infliximab biosimilars (L33394)
  • Leuteinizing Hormone-Releasing Hormone (LHRH) Analogs (Leuprolide, Goserelin, Triptorelin, Histrelin) (L33394)
  • Levocarnitine for use in the Treatment of Carnitine Deficiency in ESRD (NCD 230.19)
  • Nesiritide (Natrecor) (NCD 200.1)
  • Nivolumab (Opdivo) (L33394)
  • Omalizumab (Xolair) (L33394)
  • Paclitaxel (Taxol, Abraxane) (L33394)
  • Pegfilgrastim biosimilars (L33394)
  • PrabotulinumtoxinA (Jeuveau) (L33394)
  • Ranibizumab (Lucentis) (L33394)
  • Rituximab biosimilars (L33394)
  • Rituximab & hyaluronidase human (Rituxan Hycela) (L33394)
  • Verteporfin (Visudyne) (NCD 80.3.1)

Medications that are usually self-administered are excluded from coverage under Medicare Part B
(Per the Self-Administered Drug Exclusion List (A53022))

Questions

If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within My Quartz Tools for providers or MyChart for members or call (800) 394-5566.

This webpage was updated on March 28, 2021.