sign in sign up
<<
Home , Dacarbazine, Epoetin alfa, Pegaptanib, Pentostatin, Teniposide, Thiotepa

Vivida Health Specialty Pharmacy Drugs (Injectable) Prior-Authorization Requirements Effective 1/1/19

All Non-Par Provider Requests Requires Authorization Regardless of Service

J0178 1MG J0180 AGALSIDASE BETA 1MG J0202 ALEMTUZUMAB 1MG J0205 ALGLUCERASE PER 10 UNITS J0207 AMIFOSTINE 500MG J0220 ALGLUCOSIDASE ALFA 10MG NOS J0221 ALGLUCOSIDASE ALFA 10MG (LUMIZYME) J0256 ALPHA 1 PROTEINASE INHIBITOR (HUMAN) 10MG NOS J0257 ALPHA 1 PROTEINASE INHIBITOR HUMAN (GLASSIA) 10MG J0485 BELATACEPT 1MG J0490 10MG J0585 ONABOTULINUMTOXINA A 1 UNIT J0586 ABOBOTULINUMTOXINA A 5 UNITS J0587 RIMABOTULINUM TOXIN B 100 UNITS J0588 INCOBOTULINUM TOXIN A 1 UNIT J0594 1MG J0597 C-1 ESTERASE INHIBITOR HUMAN (BERINET) 10 UNITS J0598 C-1 ESTERASE INHIBITOR HUMAN (CYNRYZE) 10 UNITS J0637 CASPOFUNGIN ACETATE 5MG J0640 LEUCOVORIN CALCIUM 50MG J0641 LEVOLEUCOVORIN CALCIUM 0.5MG J0717 CERTOLIZUMAB PEGOL 1MG J0775 COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 0.01MG J0878 DAPTOMYCIN 1MG J0881 1MCG J0881 DARBEPOETIN ALFA 1MCG J0885 1,000 UNITS J0885 EPOETIN ALFA 1,000 UNITS J0894 1MG J0897 1MG J0897 DENOSUMAB 1MG J1290 ECALLANTIDE 1MG J1300 ECULIZUMAB 10MG J1322 ELOSULFASE ALFA 1MG

J1439 FERRIC CARBOXYMALTOSE 1MG J1442 G-CSF 1MCG J1447 TBO FILGRASTIM 1MCG J1453 FOSAPREPITANT 1MG J1458 GALSULFASE 1MG J1459 Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg J1460 Injection, gamma globulin, intramuscular, 1 cc J1556 Injection, immune globulin (bivigam), 500 mg J1557 Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg J1559 Injection, immune globulin (hizentra), 100 mg J1560 Injection, gamma globulin, intramuscular, over 10 cc J1561 Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg J1562 Injection, immune globulin (vivaglobin), 100 mg J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg J1568 Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg J1569 Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg J1571 Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml J1572 Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g., liquid), 500 mg J1573 Injection, hepatitis b immune globulin (hepagam b), intravenous, 0.5 ml J1575 Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg J1602 GOLIMUMAB FOR IV USE 1MG J1640 HEMIN 1MG J1645 DALTEPARIN SODIUM PER 2,500IU J1650 ENOXAPARIN SODIUM 10MG J1652 FONDAPARINUX SODIUM 0.5MG J1743 IDURSULFASE 1MG J1745 INFLIXIMAB 10MG J1786 IMIGLUCERASE PER 10 UNITS J1930 LANREOTIDE 1MG J1930 LANREOTIDE 1MG J1931 LARONIDASE 0.1MG J1950 LEUPROLIDE ACETATE PER 3.75MG (FOR DEPOT SUSPENSION) J2315 NALTREXONE DEPOT FORM 1MG J2323 NATALIZUMAB 1MG J2353 OCTREOTIDE DEPOT FORM INTRAMUSCULAR 1MG J2355 OPRELVEKIN 5MG J2357 OMALIZUMAB 5MG

J2426 PALIPERIDONE PALMITATE ER 1MG J2430 PAMIDRONATE DISODIUM PER 30MG J2469 PALONOSETRON 25MCG J2503 PEGAPTANIB SODIUM 0.3MG J2504 PEGADEMASE BOVINE 25IU J2505 6MG J2507 PEGLOTICASE 1MG J2562 PLERIXAFOR 1MG J2778 0.1MG J2783 RASBURICASE 0.5MG J2796 10MCG J2820 (GM-CSF) 50MCG J3060 TALIGLUCERACE ALFA 10 UNITS J3095 TELEVANCIN 10MG J3240 THYROTROPIN ALPHA 0.9MG J3262 TOCILIZUMAB 1MG J3315 TRIPTORELIN PAMOATE 3.75MG J3380 VEDOLIZUMAB 1MG J3385 VELAGLUCERASE ALFA 100 UNITS J3396 0.1MG J3489 ZOLEDRONIC ACID 1MG J3489 ZOLEDRONIC ACID 1MG J3490 UNCLASSIFIED INJECTION J7311 FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT J7312 INTRAVITREAL IMPLANT 0.1MG J7313 FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT, 0.01 MG J7323 HYALURONAN OR DERIVATIVE (EUFLEXXA) FOR INTRA- ARTICULAR INJECTION PER DOSE J7324 HYALURONAN OR DERIVATIVE (ORTHOVISC) FOR INTRA- ARTICULAR INJECTION PER DOSE J7325 HYALURONAN OR DERIVATIVE (SYNVISC OR SYNVISC ONE) FOR INTRA-ARTICULAR INJECTION 1MG J7328 HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA- ARTICULAR INJECTION, 0.1MG J7504 Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg J7511 Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg J9000 HCL 10MG J9015 ALDESLEUKIN PER SINGLE USE VIAL J9017 1MG J9019 (ERWINAZE) 1,000IU J9025 1MG J9027 1MG J9032 10MG

J9033 HCL 1MG (TREANDA) J9034 BENDAMUSTINE HCL 1MG (BENDEKA) J9035 10MG J9039 BLINATUMOMAB 1MCG J9040 SULFATE 15 UNITS J9041 0.1MG J9042 1MG J9043 1MG J9045 50MG J9047 1MG J9050 100MG J9055 10MG J9060 POWDER OR SOLUTION PER 10MG J9065 PER 1MG J9070 100MG J9098 LIPOSOME 10MG J9100 CYTARABINE HCL 100MG J9120 0.5MG J9130 100MG J9145 DARATUMUMAB 10MG J9150 10MG J9155 DEGARELIX 1MG J9160 DENILEUKIN DIFTITOX 300MCG J9171 1MG J9176 ELOTUZUMAB 1MG J9178 HCL 2MG J9179 MESYLATE 0.1MG J9181 10MG J9185 50MG J9190 500MG J9200 500MG J9201 HCL 200MG J9202 GOSERELIN ACETATE IMPLANT PER 3.6MG J9205 LIPOSOME 1MG J9206 IRINOTECAN 20MG J9207 1MG J9208 PER 1GM J9209 MESNA 200MG J9211 HYDROCHLORIDE 5MG J9214 ALFA-2B RECOMBINANT 1 MILLION UNITS

J9215 -N3 HUMAN LEUKOCYTE DERIVED 250,000IU J9217 LEUPROLIDE ACETATE FOR DEPOT SUSPENSION 7.5MG J9225 HISTRELIN IMPLANT 50MG J9228 IPILIMUMAB 1MG J9230 MECHLORETHAMINE HCL ()10MG J9245 HYDROCHLORIDE 50MG J9250 SODIUM PER 5MG J9260 METHOTREXATE SODIUM PER 50MG J9261 50MG J9262 OMACETAXINE MEPESUCCINATE 0.01MG J9263 0.5MG J9264 PROTEIN-BOUND PARTICLES 1MG J9266 PER SINGLE DOSE VIAL J9267 PACLITAXEL 1MG J9268 PER 10MG J9271 PEMBROLIZUMAB 1MG J9280 MITOMYCIN 5MG J9293 HCL PER 5MG J9295 1MG J9299 NIVOLUMAB 1MG J9301 OBINUTUZUMAB 10MG J9302 OFATUMUMAB 10MG J9303 10MG J9305 10MG J9306 1MG J9307 1MG J9308 5MG J9310 RITUXIMAB 100MG J9315 1MG J9320 STREPTOZOCIN 1GM J9328 1MG J9330 TEMSIROLIMUS 1MG J9340 15MG J9351 0.1MG J9354 ADO- EMTANSINE 1MG J9355 TRASTUZUMAB 10MG J9357 INTRAVESICAL 200MG J9360 SULFATE 1MG J9370 SULFATE 1MG J9371 VINCRISTINE SULFATE LIPOSOME 1MG

J9390 TARTRATE PER 10MG J9395 FULVESTRANT 25MG J9400 ZIV AFLIBERCEPT 1MG Q0138 FERUMOXYTOL NON-ESRD 1MG Q2017 50MG Q2043 SIPULEUCEL-T MINIMUM 50 MILLION AUTOLOGOUS C54+CELLS ACTIVATED W/PAP-GM-CSF PER INFUSION Q2049 DOXORUBICIN HCL LIPOSOMAL IMPORTED LIPODOX 10MG Q2050 DOXORUBICIN HCL LIPOSOMAL NOS 10MG Q5101 FILGRASTIM (G-CSF) 1MCG