Correction to the Biosimilar Preferred Drug List 

In a prior e-message, sent on May 16, 2022, the procedure code for trastuzumab, Herceptin, was incorrectly listed.  The correct procedure code is J9355 and is reflected in the updated table below. 

The following information provided in the prior e-message remains accurate: 

Through adoption of MaineCare Benefits Manual Chapter II, Section 90.04-7(B), Biosimilar Preferred Drug List, and pursuant to P.L. 2021, Ch. 398, Sec. A-17, An Act Making Unified Appropriations and Allocations for the Expenditures of State Government, General Fund and Other Funds and Changing Certain Provisions of the Law Necessary to the Proper Operations of State Government for the Fiscal Years Ending June 30, 2021, June 30, 2022, and June 30, 2023, the Department is implementing a Biosimilar Preferred Drug List (PDL). The Biosimilar PDL establishes preferred and non-preferred Physician-Administered Drugs (PADs). Preferred drugs are available without a Prior Authorization (PA). Providers must try preferred drugs first.  

Non-preferred drugs require a Prior Authorization (PA). PA forms are available on the Health PAS Online Portal. For the Department to consider approving a non-preferred drug, the provider must include with their PA request documentation of preferred drug failure due to lack of efficacy, intolerable side effects to the preferred drug, or clinical exceptions. Clinical exceptions include the presence of a condition that prevents usage of the preferred drug or a significant drug interaction between another drug and the preferred drug.   

Biosimilar Preferred Drug List  

Infliximab and Biosimilars  

Preferred Drugs  

Non Preferred Drugs (PA required)  

Q5121 - AVSOLA, infliximab-axxq  

Q5103 - INFLECTRA, infliximab-dyyb  

Q5104 - RENFLEXIS, infliximab-abda  

J1745 - REMICADE, infliximab  

Pegfilgrastim and Biosimilars  

Preferred Drugs  

Non Preferred Drugs (PA required)  

Q5108 - FULPHILA, pegfilgrastim-jmdb  

J2506 - NEULASTA, pegfilgrastim  

Q5120 - ZIEXTENZO, pegfilgrastim-bmez  

Q5122 - NYVEPRIA, pegfilgrastim-apgf  

  

Q5111 - UDENYCA, pegflgrastim-cbqv  

Bevacizumab and Biosimilars  

Preferred Drugs  

Non Preferred Drugs (PA required)  

Q5107 - MVASI, bevacizumab-awwb  

J9035/C9257 - AVASTIN, bevacizumab  

Q5118 - ZIRABEV, bevacizumab-bvzr  

  

Trastuzumab and Biosimilars  

Preferred Drugs  

Non Preferred Drugs (PA required)  

Q5116 - TRAZIMERA, trastuzumab-qyyp  

J9355 - HERCEPTIN, trastuzumab  

  

Q5113 - HERZUMA, trastuzumab-pkrb  

  

Q5117 - KANJINTI, trastuzumab-anns  

  

Q5114 - OGIVRI, trastuzumab-dkst  

  

Q5112 - ONTRUZANT, trastuzumab-dttb  

Please contact Tia Bolduc, Provider Relations Specialist, with questions.

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