Biosimilar Preferred Drug List (PDL) 

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 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.   

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 

J9344 - HERCEPTIN, trastuzumab 

 

Q5113 - HERZUMA, trastuzumab-pkrb 

 

Q5117 - KANJINTI, trastuzumab-anns 

 

Q5114 - OGIVRI, trastuzumab-dkst 

 

Q5112 - ONTRUZANT, trastuzumab-dttb 

 

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

 

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