art B: Prior Authorizations Update (08/2025) Form

Aspire Health Plan

IMPORTANT PROVIDER INFORMATION H8764RXPRVPartB.PA.Notice0725_C

Medicare Part B (Physician-Administered Drugs) Update: Prior Authorization

Dear Prescriber,

This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office and an update of the HCPS Codes by CMS.

Effective August 15, 2025:

The prior authorization criteria for some Part B drugs have been updated, listed in Table 1 below.
Aspire Health Plan (AHP) requires prior authorization for a select group of injectable drugs that may be administered under the medical benefit in a physician’s office or by home infusion. These reviews are intended to ensure consistent benefit adjudication as well as appropriate utilization in accordance with the AHP Pharmacy & Therapeutics Committee’s evidence-based criteria for coverage.

Table 1. Part B (Physician-Administered Drugs) Products Added to Prior Authorization List INFLIXIMAB PRODUCTS CLINICAL POLICY Brand Name (generic name) APPLICABLE HCPCS Update Summary Zymfentra J1748 J code for Zymfentra has been updated from J3590 to J1748. Added: Any U.S. Food and Drug Administration approved and launched infliximab biosimilar product not listed by name in this policy will be considered non-preferred until reviewed by Aspire Health Plan. Refer to AHP’s Infliximab Products Clinical Policy PART B MEDICAL NECESSITY POLICY Brand Name (generic name) APPLICABLE HCPCS Update Summary • Unclassified drugs or biologicals
• Unclassified drugs
• Unclassified biologics
• Unclassified drug or biological used for ESRD on dialysis
• Hemophilia clotting factor, not otherwise classified
• Compounded drug, not otherwise classified Not otherwise classified, antineoplastic drugs

C9399 J3490 J3590 J3591 J7199 J7999

  
 J9999

Added: In the absence of FDA-approved labeling of CMS approved compendia: the drug dosage, frequency, and route of administration for the treatment indication is supported by published study methodology from a major scientific or medical peer- reviewed journal article which supports the proposed drug dosage, frequency, and route of administration as safe and effective for the treatment indication.
Refer to AHP’s Part B Medical Necessity Policy

Aspire Health Plan

IMPORTANT PROVIDER INFORMATION H8764RXPRVPartB.PA.Notice0725_C TEPEZZA (teprotumumab-trbw) CLINICAL POLICY Brand Name (generic name) APPLICABLE HCPCS
Update Summary Tepezza (teprotumumab-trbw) J3241 Added: • No decrease in best-corrected visual acuity (BCVA) due to optic neuropathy in past 6 months • Moderate to severe, stable/inactive TED with: o Proptosis ≥ 3 mm from pre-TED baseline, or o Proptosis ≥ race/sex-based normal values (≥19mm for white females, ≥21mm for white males; ≥23mm for Black females, ≥24mm for Black males) • Onset of TED symptoms occurred within
the previous 9 months. Not covered if: • More than one course of Tepezza is requested • Used for cosmetic reduction in proptosis only • Patient had prior orbital irradiation or eye surgery for TED • Patient has optic neuropathy with BCVA decline, visual field, or color defect • Patient has unresponsive corneal decompensation • Any other non-approved indication or criteria not met Refer to AHP’s Tepezza (teprotumumab-trbw) Clinical Policy

Additional Information A complete list of office-administered injectable drugs requiring prior authorization and step therapy can be found on the Aspire Health Plan provider website at https://www.aspirehealthplan.org/drug-coverage/.

Please complete the updated prior authorization form at https://id.ayin.com that includes a drug section and submit it with all pertinent supporting clinical documentation to ensure a timely review. Electronic submissions are highly encouraged and often result in more timely processing by the Plan.

Thank you for the care you provide for our members, your patients. If you have any questions about this update or questions about prior authorizations, please contact us at (831) 657-0700. Sincerely,

Gilly Guez, MD, MBA Chief Medical Officer, Aspire Health Plan
Chair Pharmacy & Therapeutics Committee