Non-Self-Injectables the Following Codes Require Precertification for GHI PPO City of New York Employees/ Non-Medicare-Eligible Retirees with GHI PPO Benefits

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Non-Self-Injectables The following codes require precertification for GHI PPO City of New York Employees/ Non-Medicare-eligible retirees with GHI PPO benefits.

BRAND NAME GENERIC NAME HCPCs Histrelin acetate histrelin acetate J1675 Lupron leuprolide acetate J9218 Lupron Depot leuprolide acetate J1950 Lupron Depot leuprolide acetate J9217 Lupron Depot-Ped leuprolide acetate J1950 Lupron Depot-Ped leuprolide acetate J9217 Supprelin LA histrelin acetate J9226 Trelstar triptorelin pamoate J3315 Trelstar Depot triptorelin pamoate J3315 Trelstar LA triptorelin pamoate J3315 Vantas histrelin acetate J9225 Zoladex goserelin acetate J9202 H.P. Acthar Gel Repository corticotropin injection J0800 Mozobil Plerixafor Injection J2562 Nplate Romiplostim J2796 Euflexxa Hyaluronan J7323 Gel-One Hydrogel J7326 Hylgan Hyaluronan J7321 Monovisc Hyaluronic acid J7327 Orthovisc Hyaluronan J7324 Supartz Hyaluronan J7321 Synvisc Hyaluronan J7325 Synvisc-One Hyaluronan J7325 Actemra Tocilizumab J3262 Entyvio vedolizumab C9026 Entyvio vedolizumab J3590 Ilaris Canakinumab J0638 Lemtrada Alemtuzumab J3490 Lemtrada Alemtuzumab J3590 Orencia Abatacept J0129 Remicade Infliximab J1745 Simponi Golimumab J3590 Simponi Aria Golimumab J1602 Sylvant siltuximab J3590 Bivigam Immune globulin (Ig) Therapy J1556 Carimune NF Immune Globulin J1566 Flebogamma Immune Globulin J1572 Flebogamma 10% Immune Globulin J1572 Gamma globulin, intramuscular, 1cc Immune Globulin J1460 Gamma globulin, intramuscular, over 10cc Immune Globulin J1560 Gammagard Liq. Immune Globulin J1569 Gammagard S/D Immune Globulin J1566

1 BRAND NAME GENERIC NAME HCPCs Gammaked Immune Globulin J1561 Gammaplex Immune globulin J1557 Gamunex Liquid 10% Immune Globulin J1561 Hizentra Immune Globulin J1559 HyQvia Immune Globulin J3490 HyQvia Immune Globulin J7799 Immune globulin (Ig), Intramuscular Immune Globulin 90281 Immune globulin, intravenous, Immune Globulin J1599 nonlyophilized, 500mg IVIG Generic Immune Globulin 90283 Octagam Liquid 5% or 10% Immune Globulin J1568 Privigen Immune Globulin J1459 SCIg Immune Globulin Subcutaneous (human) 90284 Duodopa levodopa/carbidopa J3490 Nulojix Belatacept J0485 Abraxane Paclitaxel protein-bound J9264 Adcetris Brentuximab vedotin J9042 Alimta Pemetrexed Disodium J9305 Arzerra Ofatumumab J9302 Avastin (Oncoloytics) Bevacizumab J9035 Campath Alemtuzumab J9010 Cyramza ramucirumab C9025 Cyramza ramucirumab J3590 Erbitux Cetuximab J9055 Erwinaze Asparaginase J9019 Gazyva Obinutuzumab J9301 Halaven Eribulin mesylate J9179 Herceptin Trastuzumab J9355 Hycamtin Topotecan HCL J9351 Jevtana Cabazitaxel J9043 Kadcyla Ado-trastuzumab emtansine J9354 Keytruda pembrolizumab C9027 Keytruda pembrolizumab J9999 Kyprolis Carfilzomib J9047 Oncaspar Asparaginase J9266 Perjeta Pertuzumab J9306 Proleukin Aldesleukin J9015 Provenge sipuleucel-T Q2043 Rituxan Rituximab J9310 Vectibix Panitumumab J9303 XGEVA denosumab J0897 Yervoy Ipilimumab J9228 Zaltrap Ziv-aflibercept J9400 Berinert C1 esterase inhibitor (human) J0597 Cinryze C1 esterase inhibitor (human) J0598 Firazyr Icatibant J1744 Kalbitor Ecallantide J1290

2 BRAND NAME GENERIC NAME HCPCs Ruconest recombinant C1esterase inhibitor C9445 Ruconest recombinant C1esterase inhibitor J3590 Prialt Ziconotide Intrathecal Infusion J2278 Prolia denosumab J0897 Flolan Epoprostenol J1325 Remodulin Treprostinil J3285 TYVASO Treprostinil J7686 Veletri Epoprostenol J1325 Ventavis Lloprost Q4074 Aralast Alpha 1 proteinase inhibitor J0256 Aralast NP Alpha 1 proteinase inhibitor J0256 Glassia Alpha 1 proteinase inhibitor J0257 Prolastin Alpha 1 proteinase inhibitor J0256 Prolastin-C Alpha 1 proteinase inhibitor J0256 Zemaira Alpha 1 proteinase inhibitor J0256 Aranesp, ESRD Darbepoetin Alfa J0882 Aranesp, Non-ESRD Darbepoetin Alfa J0881 Epogen ESRD 100 Units Epoetin Alfa Q4081 Epogen ESRD 1000 Units Epoetin Alfa J0886 Epogen Non ESRD Epoetin Alfa J0885 Micera epoetin beta J0887 Micera epoetin beta J0888 Procrit ESRD 100 Units Epoetin Alfa Q4081 Procrit ESRD 1000 Units Epoetin Alfa J0886 Procrit Non ESRD Epoetin Alfa J0885 Avastin 0.25 mg Bevacizumab C9257 Avastin 0.25 mg intravitreal Bevacizumab J3590 Eylea Aflibercept J0178 Iluvien Fluocinolone acetonide, intravitreal J7311 implant Jetrea Ocriplasmin J7316 Lucentis Ranibizumab J2778 Macugen Pegaptanib J2503 Ozurdex Dexamethasone intravitreal implant J7312 Retisert Fluocinolone acetonide, intravitreal J7311 implant Soliris eculizumab J1300 Synagis Palivizumab 90378 Prokine Sargramostim J2820 Granix ) Tbo-filgrastim J1446 Leukine Sargramostim J2820 Neulasta Pegfilgrastim J2505 Neupogen Filgrastim J1442 Xiaflex Clostridial collagenase histolyticum J0775 Xolair Omalizumab J2357 Hemofil M Antihemophilic factor (factor VIII) human J7190 plasma-derived

3 BRAND NAME GENERIC NAME HCPCs Wilate Antihemophilic factor VIII J7183 Alphanate Antihemophilic factor VIII J7186 Humate-P Antihemophilic factor VIII J7187 Feiba NF Anti-inhibitor coagulant complex J7198 AlphaNine SD Coagulation factor IX (human) J7193 Soliris® eculizumab J1300 Bebulin VH Factor IX Complex Human J7194 Benefix Factor IX Recombinant J7195 Rixubis Factor IX Recombinant J7200 Novoseven RT Factor VIIa Recombinant J7189 Xyntha Factor VIII (antihemophic factor, J7185 recombinant) Advate Factor VIII (antihemophic factor, J7192 recombinant) Corifact Factor XIII concentrate (human) J7180 RiaSTAP Fibrinogen concentrate J7178 Mozobil Plerixafor Injection J2562 Eloctate Recombinant Antihemophilic Factor Q9975 Alprolix Recombinant Coagulation Factor IX J7201