Medications to Require Medical Prior Authorization

EFFECTIVE January 1, 2021 November 2020

As a part of our continuous efforts to improve the quality of care for our members, Gateway Health will require prior authorization for the following effective with dates of service beginning January 1, 2021. This authorization requirement applies to Medicare Assured members. Failure to obtain authorization will result in a claim denial. Medical necessity criteria for each of the medications listed below are outlined in the specific policies available online. To access Gateway Health medication policies, please paste the following link in your internet browser: https://www.gatewayhealthplan.com/provider/medicare-resources/medicare-medical-policy. Procedure Codes Requiring Authorization

Procedure Code Description Procedure Code Description

J0129 abatacept (Orencia) J1744 (Firazyr)

J0586 abobotulinumtoxina (Dysport) J1743 idursulfase (Elaprase)

J0135 (Humira) Q4074 Iloprost (Ventavis)

J3490* afamelanotide (Scenesse) J1556 immune globulin (Bivigam)

J0178 aflibercept (Eylea) J1572 immune globulin (Flebogamma DIF)

J0180 agalsidase beta (Fabrazyme) J1560 immune globulin (Gamastan S/D)

J0202 alemtuzumab (Lemtrada) J1460 immune globulin (Gamastan S/D)

J0257 alpha 1 proteinase inhibitor (Glassia) J1569 immune globulin (Gammagard)

alpha 1- proteinase inhibitor (human) (Aralast J3590* immune globulin-hipp (Cutaquig) J0256 NP, Prolastin-C, & Zemaira)

J0270 alprostadil (Caverject & Edex) J1558 immune globulin-klhw (Xembify)

J3590* asfotase alfa (Strensiq) J0588 incobotulinumtoxin a (Xeomin)

J7330 autologous cultured chondrocyte (MACI) J3590* inebilizumab-cdon (Uplizna)

Q2041 axicabtagene ciloleucel (Yescarta) Q5103 (Inflectra)

J0490 (Benlysta) J1745 infliximab (Remicade)

J0517 (Fasenra & Fasenra Pen Q5104 infliximab (Renflexis)

J9035 bevacizumab (Avastin) Q5121 infliximab-axxq (Avsola)

J7351 bimatoprost implant (Durysta) Q5109 infliximab-qbtx (Ixifi)

J1632 brexanolone (Zulresso) J3490* inotersen (Tegsedi)

J0584 burosumab-twza (Crysvita) J9216 interferon gamma 1-b (Actimmune)

J0597 c-1 esterase inhibitor human (Berinert) J0593 -flyo (Takhzyro)

J0598 c-1 esterase inhibitor human (Cinryze) J9218 leuprolide acetate

J0596 c1 esterase inhibitor recombinant (Ruconest) J3490* leuprolide acetate (Fensolvi)

J0599 c-1 esterase inhibitor, human (Haegarda) J0896 luspatercept-aamt (Reblozyl)

J0630 calcitonin salmon (Miacalcin) J2182 (Nucala)

J0638 (Ilaris) J3490* metreleptin (Myalept ) These medications will be reviewed under the applicable miscellaneous procedure code until a permanent code is assigned

Medications to Require Medical Prior Authorization

EFFECTIVE January 1, 2021 November 2020

Procedure Code Description Procedure Code Description

J7340 carbidopa/levodopa (Duopa) J7401 mometasone furoate sinus implant (Sinuva)

J0717 (Cimzia) J8499* monomethyl fumarate (Bafiertam)

J1201 cetirizine hydrochloride (Quzyttir) J3590* ofatumumab (Kesimpta)

J0775 collagenase, clostridium histolyticum (Xiaflex) J2357 (Xolair)

J0800 corticotropin (Acthar) J0585 onabotulinumtoxina (Botox) J0791 -tmca (Adakveo) J2502 pasireotide long acting (Signifor LAR) J9155 degarelix (Firmagon) J0222 patisiran (Onpattro) peanut (Arachis hypogaea) allergen powder- J0897 denosumab (Prolia; Xgeva) J8499* dnfp (Palforzia) J3590* (Dupixent) J2503 pegaptanib sodium (Macugen)

J1290 ecallantide (Kalbitor) Q5120 pegfilgrastim-bmez (Ziextenzo)

J1301 edaravone (Radicava) J2507 pegloticase (Krystexxa) J3032 eptinezumab-jjmr (Vyepti) J3590* pegvisomant (Somavert) pertuzumab, trastuzumab, and - J3490* esketamine nasal (Spravato) J9999* zzxf (Phesgo) J1438 etanercept (Enbrel) J9600 porfimer sodium (Photofrin)

J1439 ferric carboxymaltose (Injectafer) J2778 ranibizumab (Lucentis)

J1437 ferric derisomaltose (Monoferric) J2786 (Cinqair)

Q0138 ferumoxytol (Feraheme) J2793 rilonacept (Arcalyst)

J3031 fremanezumab-vfrm (Ajovy) J0587 rimabotulinumtoxinb (Myobloc)

J1458 galsulfase (Naglazyme) J8499 risdiplam (Evrysdi)

J8565 gefitinib (Iressa) Q5119 rituximab-pvvr (Ruxience) J0223 givosiran (Givlaari) J3590* -mqge (Enspryng) J1602 (Simponi Aria) J7331 sodium Hyaluronate (Synojoynt) somatropin (Genotropin; Humatrope; J1429 golodirsen (Vyondys 53) J2941 Norditropin; Nutropin; Omnitrope; Saizen; Serostim; Zomacton; Zorbtive) J1675 histrelin acetate (Vantas) J3060 taliglucerase alfa (Elelyso)

J9226 histrelin implant (Supprelin LA) J3241 teprotumumab-trbw (Tepezza)

J7323 hyaluronan sodium (Euflexxa) J3245 -asmn (Ilumya)

J7322 hyaluronate acid (Hymovis) Q2042 tisagenlecleucel (Kymriah)

J7326 hyaluronate sodium (Gel-One) J3262 (Actemra) J7328 hyaluronate sodium (Gelsyn-3) Q5113 trastuzumab-pkrb (Herzuma) These medications will be reviewed under the applicable miscellaneous procedure code until a permanent code is assigned

Medications to Require Medical Prior Authorization

EFFECTIVE January 1, 2021 November 2020

Procedure Code Description Procedure Code Description

J7320 hyaluronate sodium (Genvisc 850) J3285 treprostinil (Remodulin)

J7321 hyaluronate sodium (Hyalgan & Supartz FX) J7686 treprostinil (Tyvaso)

J7329 hyaluronate sodium (Trivisc) J3315 triptorelin pamoate (Trelstar)

J7333 hyaluronate sodium (Visco-3) J3357 (Stelara)

J7318 hyaluronic acid (Durolane) J3358 ustekinumab (Stelara)

J7327 hyaluronic acid (Monovisc) J3380 (Entyvio)

J7324 hyaluronic acid (OrthoVisc) J3385 velaglucerase alfa (Vpriv)

J1726 hydroxyprogesterone caproate (Makena) J3396 verteporfin (Visudyne) hylan polymers A and B (Synvisc & Synvisc J3397 vestronidase alfa-vjbk (Mepsevii) J7325 One) J1746 -uiyk (Trogarzo) J3490* viltolarsen (Viltepso)

J1740 ibandronate sodium (Boniva) J3489 zoledronic acid (Reclast; Zometa) These medications will be reviewed under the applicable miscellaneous procedure code until a permanent code is assigned

Additional Information Questions? • Any decision to deny a prior authorization is made by a licensed pharmacist based on If you have questions individual member needs, characteristics of regarding the authorization the local delivery system, and established clinical criteria. process and how to • NaviNet is the most efficient means to request authorization. A new NaviNet form submit authorizations with autofill functionality will be added to the Authorization Request Forms to make electronically, please completing and submitting your online requests easier and faster. contact your Gateway Health Provider Relations • The prior authorization look up tool (accessed via NaviNet) will be updated to show Representative directly prior authorization requirements for these medications. or Gateway Health • For a smooth transition to the prior authorization process, you may begin to submit Pharmacy Services authorization requests beginning December 21, 2020 for dates of service on using the phone number January 1, 2021 and beyond. Medicare: • Authorization does not guarantee payment of claims. Medications listed above will 1-800-685-5209. be reimbursed by Gateway Health only if it is medically necessary, a covered service, and provided to an eligible member. • Non-covered benefits will not be paid unless special circumstances exists. Always review member benefits to determine covered and non-covered services.