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Prior Authorization for Medicare Part B Drugs


Providers: For the quickest turn-around on prior authorizations, submit your request through Availity.

Members: Usually, your provider handles prior authorization requests for you, but you can ask for one yourself. Learn how to ask for a prior authorization.

The Medicare Part B drugs listed below require prior authorization. We give the generic name first, followed by the brand name in italics, so it's Generic Name (Brand Name).

Oncology Drugs

A

Abemaciclib (Verzenio)

Abiraterone (Zytiga)

Abiraterone micronized (Yonsa)

Acalabrutinib (Calquence)

Acitretin (Soriatane)

Ado-trastuzumab emtansine (Kadcyla)

Afatinib (Gilotrif)

Albumin (Human) 5%, 250 ml (Albumin (Human))

Albumin (Human) 25%, 20 ml (Albumin (Human))

Albumin (Human) 25%, 50 ml (Albumin (Human))

Aldesleukin single-use vial, injection (Proleukin)

Alectinib (Alecensa)

Altretamine (Hexalen)

Amifostine 500 mg injection (Ethyol)

Anastrozole (Arimidex)

Antithymocyte globulin (Atgam)

Apalutamide (Erleada)

Aprepitant injection (Cinvanti)

Aprepitant oral 5 mg (Emend)

Arsenic trioxide 1 mg injection (Trisenox)

Atezolizumab (Tecentriq)

Avatrombopag (Doptelet)

Avelumab (Bavencio)

Axitinib (Inlyta)

Azacitidine 1 mg injection (Vidaza)

B

BCG per instillation (TheraCys, Tice)

Belinostat (Beleodaq)

Bendamustine HCl 1 mg injection (Treanda)

Bendamustine rapid-infusion formulation (Bendeka)

Bevacizumab 10 mg injection (Avastin)

Bevacizumab-awwb (Mvasi)

Bexarotene (Targretin)

Bicalutamide (Casodex)

Binimetinib (Mektovi)

Bleomycin sulfate 15 units, injection (Blenoxane)

Blinatumomab (Blincyto)

Bortezomib 0.1 mg injection (Velcade)

Bosutinib (Bosulif)

Brentuximab (Adcetris)

Brigatinib (Alunbrig)

Busulfan 1 mg injection (Busulfex)

Busulfan oral 2 mg (Myleran)

C

Cabazitaxel (Jevtana)

Cabozantinib (Cabometyx, Cometriq)

Calcitonin salmon (Miacalcin)

Calcium gluconate (Calcium gluconate)

Capecitabine oral 150 mg (Xeloda)

Capecitabine oral 500 mg (Xeloda)

Carboplatin 50 mg injection (Paraplatin)

Carfilzomib (Kyprolis)

Carmustine 100 mg injection (BiCNU)

Ceritinib (Zykadia)

Cetuximab 10 mg injection (Erbitux)

Chlorambucil (Leukeran)

Cimetidine injection (Tagamet)

Cimetidine oral (Tagamet)

Cisplatin powder or solution 10 mg injection (Plaintol)

Cladribine per 1 mg, injection (Leustatin)

Cofarabine 1 mg injection (Clolar)

Cobimetinib (Cotellic)

Copanlisib (Aliqopa)

Crizotinib (Xalkori)

Cyclophosphamide 100 mg (Cytoxan)

Cyclophosphamide oral 25 mg (Cytoxan)

Cyclosporine (Neoral, Sandimmune)

Cyclosporine oral 100 mg (Neoral, Sandimmune)

Cytarabine 100 mg injection (Cytosar-U)

Cytarabine liposome 10 mg injection (Depocyt)

D

Dabrafenib (Tafinlar)

Dacarbazine 100 mg (DTIC-Dome)

Dactinomycin 0.5 mg injection (Cosmegen)

Daratumumab (Darzalex)

Darbepoetin alfa 1 mcg injection for non-ESRD use (Aranesp)

Dasatinib (Sprycel)

Daunorubicin and cytarabine liposome (Vyxeos)

Daunorubicin 10 mg injection (Daunorubicin)

Decitabine 1 mg injection (Dacogen)

Deferasirox (Exjade)

Deferiprone (Ferriprox)

Deferoxamine mesylate 500 mg injection (Desferal)

Degarelix 1 mg injection (Firmagon)

Denosumab injection (Prolia, Xgeva)

Dexamethasone oral 0.25 mg (Decadron)

Dexamethasone sodium phosphate 1 mg injection (Dexamethasone)

Dexrazoxane HCl per 250 mg, injection (Zinecard)

Diphenhydramine HCl 50 mg oral (Benadryl)

Diphenhydramine HCl up to 50 mg, injection (Benadryl)

Dipyridamole injection (Dipyridamole)

Docetaxel 1 mg injection (Taxotere)

Dolasetron mesylate 10 mg injection (Anzemet)

Dolasetron mesylate oral (Anzemet)

Doxorubicin HCl injection (Adriamycin)

Dronabinol oral 2.5 mg (Marinol)

Dronabinol oral 5 mg (Marinol)

Dronabinol oral solution (Syndros)

Droperidol injection (Inapsine)

Durvalumab (Imfinzi)

E

Eltrombopag (Promacta)

Elotuzumab (Empliciti)

Enasidenib (Idhifa)

Encorafenib (Braftovi)

Enzalutamide (Xtandi)

Epinephrine injection (Adrenalin)

Epirubicin (Ellence)

Epoetin alfa for non-ESRD use 1000 units, injection (Procrit, Epogen)

Epoetin alfa-epbx (Retacrit)

Epoetin beta for non-ESRD use (Mircera)

Eribulin mesylate injection (Halaven)

Erlotinib (Tarceva)

Erwinaze injection (Erwinaze)

Estramustine (Emcyt)

Estrogen conjugated injection (Premarin)

Ethinyl estradiol (Estinyl)

Etoposide oral 50 mg (Vepesid)

Etoposide 10 mg injection (Vepesid)

Everolimus oral (Afinitor)

Exemestane (Aromasin)

F

Famotidine injection (Pepcid)

Famotidine oral (Pepcid)

Ferric carboxymaltose (Injectafer)

Ferumoxytol Tx iron deficiency anemia 1 Mg non-ESRD, injection (Feraheme)

Fexofenadine (Allegra)

Filgrastim G-CSF 1 mcg injection (Neupogen)

Filgrastim-aafi (Nivestym)

Filgrastim-sndz (Zarxio)

Flebogamma injection (Flebogamma)

Floxuridine 500 mg injection (FUDR)

Fludarabine phosphate 50 mg injection (Fludara)

Fluorouracil 500 mg injection (Adrucil)

Fluoxymesterone (Halotestin)

Flutamide (Eulexin)

Folic acid (Folic acid)

Fosaprepitant 1 mg injection (Emend)

Fostamatinib (Tavalisse)

Fulvestrant 25 mg injection (Faslodex)

G

Gamma globulin intramuscular, 1 cc (Gamastan S/D, Immune Globulin)

Gamma globulin intramuscular, 10 cc (Gamastan S/D, Immune Globulin)

Gammaplex injection (Gammaplex)

Gamunex, Gamunex-C, Gammaked (Gamunex, Gamunex-C, Gammaked)

Gefitinib (Iressa)

Gemcitabine HCl 200 mg injection (Gemzar)

Gemtuzumab ozogamicin 5 mg (Mylotarg)

Glucarpidase (Voraxaze)

Goserelin acetate implant per 3.6 mg (Zoladex)

Granisetron HCl 100 mcg injection (Kytril)

Granisetron HCl extended release injection (Sustol)

Granisetron HCl oral 1 mg (Kytril)

Granisetron transdermal patch, 3.1 mg/24 hours (Sancuso)

H

Haloperidol injection (Haldol)

Histrelin implant 50 mg (Vantas)

Hydrocortisone oral (Hydrocortisone)

Hydrocortisone sodium succinate to 100 mg, injection (Solu-Cortef)

Hydroxyurea (Hydrea)

Hhydroxyzine HCl up to 25 mg, injection (Hydroxyzine)

Hydroxyzine pamoate 25 mg (Atarax)

Hydroxyzine pamoate 50 mg (Atarax)

I

Ibrutinib (Imbruvica)

Idarubicin HCl 5 mg injection (Idamycin)

Idelalisib (Zydelig)

Ifosfamide 1 g injection (Ifex)

Imatinib mesylate (Gleevec)

Immune globulin (Carimune NF)

Immune globulin IV non-lyophilized 500 mg injection (Gammagard, Octagram, Privigen)

Immune globulin injection 500 mg (Bivigam)

Immune globulin powder (Immune globulin)

Immune globulin subcutaneous (Human) (Cuvitru)

Immune globulin/hyaluronidase 100 mg immune globulin (Hyqvia)

Imported lipodox injection (Lipodox)

Inotuzumab ozogamicin (Besponsa)

Interferon alfa-2b recombinant 1 M U, injection (Intron A)

Interferon gamma-1b (Actimmune)

Ipilimumab (Yervoy)

Irinotecan 20 mg injection (Camptosar)

Irinotecan liposome (Onivyde)

Iron dextran injection (Infed, Dexferrum)

Iron sucrose 1 mg injection (Venofer)

Isotretinoin (Accutane)

IVIG non-lyophilized, nos 500Mg (Immune globulin)

Ivosidenib (Tibsovo)

Ixabepilone 1 mg (Ixempra Kit)

Ixazomib (Ninlaro)

K

Ketoconazole (Nizoral)

L

L-glutamine oral powder (Endari)

Lanreotide (Somatuline Depot)

Lapatinib (Tykerb)

Lenalidomide (Revlimid)

Lenvatinib (Lenvima)

Letrozole (Femara)

Leucovorin calcium per 50 mg, injection (Leucovorin)

Leucovorin oral (Leucovorin)

Leuprolide acetate implant (Viadur)

Leuprolide acetate injection (Lupron injection, self-administered)

Leuprolide acetate suspension (Eligard, Lupron Depot)

Leuprolide acetate suspension 3.75 mg (Lupron Depot)

Levoleucovorin calcium 0.5 mg injection (Fulsilev)

Liposomal doxorubicin (Doxil)

Lomustine (Ceenu)

Loperamide (Imodium)

Lutetium Lu 177 dotatate (Lutathera)

M

Magnesium sulfate per 500 mg, injection (Magnesium Sulfate)

Mannitol 25% in 50 ml injection (Mannitol)

Mechlorethamine 0.016% topical gel (Valchlor)

Mechlorethamine HCl 10 mg injection (Mustargen)

Medroxyprogesterone acetate injection (Depo-Provera)

Medroxyprogesterone oral (Provera)

Megestrol acetate (Megace)

Melphalan Captisol-enabled (Evomela)

Melphalan HCl 50 mg injection (Alkeran)

Melphalan oral 2 mg (Alkeran)

Mercaptopurine (Purinethol, Purixan)

Mesna 200 mg injection (Mesnex)

Mesna oral (Mesnex)

Methotrexate oral 2.5 mg (Methotrexate)

Methotrexate sodium injection 5 mg (Methotrexate)

Methotrexate sodium injection 50 mg (Methotrexate)

Methoxsalen injection (Uvadex)

Methoxsalen oral (8-MOP)

Methylnaltrexone (Relistor)

Methylprednisolone sodium succnat to 125 mg, injection (Solumedrol)

Methylprednisolone sodium succnat to 40 mg, injection (Solumedrol)

Metoclopramide HCl oral (Reglan)

Metoclopramide HCl up to 10 mg, injection (Reglan)

Midostaurin (Rydapt)

Mitomycin 5 mg (Mutamycin)

Mitotane (Lysodren)

Mitoxantrone HCl per 5 mg, injection (Novantrone)

N

Nabilone oral (Cesamet)

Necitumumab (Portrazza)

Nelarabine 50 mg injection (Arranon)

Neratinib (Nerlynx)

Netupitant/Palonosetron (Akynzeo)

Nilotinib (Tasigna)

Nilutamide (Nilandron)

Niraparib (Zejula)

Nivolumab (Opdivo)

O

Obinutuzumab (Gazyva)

Octreotide depot form IM injection 1 mg (Sandostatin LAR Depot)

Octreotide non-depot form Subq/IV injection 25 mcg (Sandostatin)

Ofatumumab injection (Arzerra)

Olaparib capsules (Lynparza)

Olaparib tablets (Lynparza)

Olaratumab (Lartruvo)

Omacetaxine (Synribo)

Ondansetron HCl 8 mg oral (Zofran)

Ondansetron HCl per 1 mg, injection (Zofran)

Osimertinib (Tagrisso)

Oxaliplatin 0.5 mg injection (Eloxatin)

P

Paclitaxel injection (Taxol)

Paclitaxel protein-bound particles 1 mg injection (Abraxane)

Palbociclib (Ibrance)

Palifermin injection (Kepivance)

Palonosetron HCl 25 mcg injection (Aloxi)

Pamidronate disodium per 30 mg, injection (Aredia)

Panitumumab 10 mg injection (Vectibix)

Panobinostat (Farydak)

Pazopanib (Votrient)

Pegaspargase per single dose vial, injection (Oncaspar)

Pegfilgrastim delivery kit, on-body injector (Neulasta)

Pegfilgrastim injection (Neulasta)

Pegfilgrastim-jmdb (Fulphila)

Peginterferon alfa-2a (Pegasys)

Peginterferon alfa-2b (Pegintron, Sylatron)

Pembrolizumab (Keytruda)

Pemetrexed 10 mg injection (Alimta)

Pentostatin 10 mg injection (Nipent)

Pertuzumab (Perjeta)

Phytonadione (Mephyton)

Plerixafor injection (Mozobil)

Pomalidomide (Pomalyst)

Ponatinib (Iclusig)

Porfimer sodium 75 mg injection (Photofrin)

Potassium chloride per 2 meq, injection (Potassium choride)

Pralatrexate 1 mg injection (Folotyn)

Prednisolone oral (Millipred)

Prednisone oral per 5 mg (Prednisone)

Procarbazine (Matulane)

Prochlorperazine maleate oral 5 mg (Compazine)

Prochlorperazine to 10 mg, injection (Compazine)

Promethazine HCl 12.5 mg oral (Phenergan)

Promethazine HCl up to 50 mg, injection (Phenergan)

R

Raloxifene (Evista)

Ramucirumab (Cyramza)

Ranitidine HCl 25 mg injection (Zantac)

Ranitidine oral (Zantac)

Rasburicase 0.5 mg injection (Elitek)

Regorafenib (Stivarga)

Rho(D) immune globulin H, S/D (WinRho SDF)

Ribociclib (Kisqali)

Rituximab 100 mg injection (Rituxan)

Rituximab and hyaluronidase human (Rituxan Hycela)

Rolapitant injection (Varubi)

Rolapitant oral 1 mg (Varubi)

Romidepsin injection (Istodax)

Romiplostim 10 mcg injection (Nplate)

Rucaparib (Rubraca)

Ruxolitinib (Jakafi)

S

Sargramostim 50 mcg injection (Leukine)

Siltuximab (Sylvant)

Sipuleucel-T Auto CD5+ (Provenge)

Sodium ferric gluconate (Ferrlecit, Nulecit)

Sonidegib (Odomzo)

Sorafenib (Nexavar)

Streptozocin 1 g injection (Zanosar)

Sunitinib (Sutent)

T

Talimogene laherparepvec (Imlygic)

Tamoxifen (Nolvadex)

Tbo-filgrastim (Granix)

Telotristat ethyl (Xermelo)

Temozolomide 1 mg injection (Temodar)

Temozolomide oral 5 mg (Temodar)

Temsirolimus 1 mg injection (Torisel)

Teniposide 50 mg (Vumon)

Testosterone cypionate up to 100 mg, injection (Depo-Testosterone)

Testosterone enanthate up to 100 mg, injection (Delatestryl)

Testosterone pellet (Testopel)

Testosterone undecanoate 1 mg injection (Aveed)

Thalidomide (Thalomid)

Thiamine HCl 100 mg injection (Thiamine)

Thioguanine (Tabloid)

Thiotepa 15 mg injection (Thioplex)

Thyrotropin injection (Thyrogen)

Topotecan 0.1 mg injection (Hycamtin)

Topotecan oral 0.25 mg (Hycamtin)

Toremifene (Fareston)

Trabectedin (Yondelis)

Trametinib (Mekinist)

Trastuzumab 10 mg injection (Herceptin)

Trastuzumab-dkst (Ogivri)

Tretinoin (ATRA, Vesanoid)

Trifluridine and tipiracil (LONSURF)

Triptorelin pamoate 3.75 mg injection (Trelstar)

V

Valrubicin intravesical 200 mg injection (Valstar)

Vandetanib (Caprelsa)

Vemurafenib (Zelboraf)

Venetoclax (Venclexta)

Vinblastine sulfate 1 mg injection (Velban)

Vincristine liposomal (Marqibo)

Vincristine sulfate 1 mg (Oncovin)

Vinorelbine tartrate 10 mg injection (Navelbine)

Vismodegib (Erivedge)

Vitamin B-12 Cyanocobalamin to 1000 mcg, injection (Cyanocobalamin)

Vorinostat (Zolinza)

Z

Ziv-aflibercept injection (Zaltrap)

Zoledronic acid injection (Reclast, Zometa)

Other Drugs

A

Adalimumab (Humira)

Aflibercept (Eylea)

C

C-1 esterase inhibitor (Human) injection, 10 units (Berinert, Cinryze)

Certolizumab pegol (Cimzia)

D

Darbepoetin alfa in polysorbat for ESRD (Aranesp for ESRD)

E

Eculizumab (Soliris)

Epoprostenol Sodium (Glycine) (Flolan, Veletri)

Etanercept (Enbrel)

G

Golimumab (Simponi Aria)

H

Hemin (Panhematin)

Hyaluronate sodium, stabilized (Monovisc)

Hyaluronate sodium (Orthovisc)

Hylan G-F 20 (Synvisc, Synvisc-One)

I

Iloprost tromethamine (Ventavis)

Immunoglublin G (IgG)/Pro/IgA 0-50 (Hizentra)

Infliximab (Remicade)

Interferon beta-1a injection, 1 mcg for intramuscular use (Avonex)

Interferon beta-1a injection, 1 mcg for subcutaneous use (Avonex)

Ipilimumab (Yervoy)

N

Natalizumab (Tysabri)

O

Octreotide acetate, mi-spheres (Sandostatin LAR, Sandostatin LAR Depot)

Omalizumab (Xolair)

Onabotulinum toxin A (Botox)

P

Pegloticase (Krystexxa)

R

Ranibizumab (Lucentis)

T

Tocilizumab (Actemra)

Treprostinil (Tyvaso)

Treprostinil sodium (Remodulin)

U

Ustekinumab (Stelara)