Medicare Prior Authorization List Effective 1/1/2021

Medicare Prior Authorization List effective 1/1/2021

Dear Participating Allwell from PA Health & Wellness Provider,

Allwell from PA Health & Wellness requires prior authorization as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Allwell from PA Health & Wellness.

Allwell from PA Health & Wellness is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Thank you for your continued partnership,

Allwell from PA Health & Wellness

Effective January 1st, 2021, Prior Authorization will be required for the following services:

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on Health Plan website at https://www.pahealthwellness.com/providers/preauth-check/medicare-pre-auth.html

Service Category Services/Procedures Comments

Prior Auth Required: • Health Net Medicare Advantage for California • Arizona Complete Health • Oregon Health Net Medicare Advantage • Allwell from MHS - MHS Indiana • Allwell from Sunflower An alternate form of medicine in which thin needles are • Allwell from Louisiana Healthcare Connections inserted into the body. Medicare doesn't cover acupuncture • Allwell from Superior HealthPlan (MA & MMP) Acupuncture (including dry needling) for any condition other than chronic • Allwell Medicare Advantage from MHS Health Wisconsin low back pain. Limit to 20 visits. • Ascension Complete (FL, IL, KS)

Contracted Providers: Visit ashlink.com Non-Contracted providers: Call 877-248-2746

Ambulance Nonemergent Fixed Wing Requires prior authorization before transport Day Treatment Electroconvulsive Therapy (ECT) Inpatient Psychiatric Intensive Outpatient Therapy Behavioral Health Services Neuropsychological Testing Partial hospitalization Psychological Testing Substance Use Disorder Treatment/Rehabilitation

Bronchial Thermoplasty Outpatient procedure for the treatment of asthma

Service Category Services/Procedures Comments

Prior Auth Required: • Health Net Medicare Advantage for California • Arizona Complete Health Medicare coverage for chiropractic services extends only to • Oregon Health Net treatment by means of manual manipulation of the spine to • Allwell from Louisiana Healthcare Connections Chiropractor Services correct a subluxation, provided such treatment is reasonable and medically necessary Contracted Providers: Visit ashlink.com Non-Contracted providers: Call 877-248-2746

A clinical trial is one type of clinical research that follows a Clinical Trials: Notification Only pre-defined plan or protocol

Provides direct electrical stimulation to the auditory nerve, Cochlear Implants & Surgery bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea

Includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member Including, but not limited to the following: Cosmetic Procedures/Dermatology Chemical exfoliation, electrolysis Dermabrasion/chemical peel Laser treatment Skin injections and implants Drug Testing Quantitative tests for drugs of abuse Ambulatory Infusion Pumps BIPAP Bone Growth Stimulator Continuous Glucose Monitor Hospital Bed/Mattress Implantable Neurostimulator Lift Devices including Hoyer Durable Medical Equipment (DME) Lymphedema Pumps and Supplies TENS Units Vagus Nerve Stimulator

Ventilators

Wheelchairs, Custom

Wheelchairs, Power

Wound Vacuum (Negative Pressure) Devices

Service Category Services/Procedures Comments

Enhanced External Counterpulsation The noninvasive outpatient treatment for patients with (EECP) coronary artery disease (CAD)

Any item or service potentially considered investigational or Experimental/Investigational Services experimental must be authorized in advance

General term to describe a surgery or surgeries that affirm a Gender Reassignment person's gender identity

Genetic testing is a type of medical test that identifies Genetic Counseling and Testing changes in chromosomes, genes, or proteins Infertility Drug Therapy, Testing, Treatment Home Health Aide Occupational Therapy Physical Therapy Home Health Services Skilled Nursing Visits Social Work Visits Speech Therapy Hospice: Notification only Home or Inpatient Acute Inpatient Hospital Inpatient Rehabilitation Hospital Hospital Admission Long Term Acute Care Hospital (LTAC) Skilled Nursing Facility (SNF) Hyperbaric O2 Therapy Includes HBO therapy administered in a chamber

Evaluations for members with a history of psychological, Neuropsychological Testing neurologic or medical disorders known to impact cognitive or neurobehavioral functioning Nutritional Supplements and/or Formula administered via a enteral feeding tube services Observation Stay Prior Authorization required if >48 hours Prosthetic devices needed to replace a body part or function

Orthotics/Prosthetics Limited coverage options for orthotic shoes and devices, including artificial limbs and eyes as well as braces for arms, legs, back, or neck, penile prosthetics

Service Category Services/Procedures Comments

Outpatient Therapy Therapeutic treatment: as a remedial treatment of mental or Requires authorization after 12 combined visits bodily disorder or · Occupational Therapy an agency (as treatment) designed or · Physical Therapy serving to bring about rehabilitation or social adjustment

· Speech-Language Therapy Facet Injections Median Branch Block Pain Management Radio Frequency Ablation Sacroiliac joint injection (SI) Trigger Point Part B Drugs See attached Appendix A Intensity modulated radiotherapy (IMRT) Neutron beam therapy Radiation Therapy Proton beam therapy Stereotactic radiotherapy Cardiac Imaging All Health Plans Excluding CT Allwell Medicare Advantage Radiology MRA from MHS Health Wisconsin MRI, MRA, PET Scan, CT, Cardiac Imaging visit www.radmd.com

PET

Surgery and treatment Sleep Studies Hospital Sleep Study

Abortion Bariatric Surgery Blepharoplasty Breast Augmentation (except following mastectomy) Breast Reduction

Capsule Endoscopy

Surgeries, regardless of place of service Chondrocyte Implants

Cochlear Implant

Facial Osteotomy

Hysterectomy Joint Replacements Mastectomy for Gynecomastia

Service Category Services/Procedures Comments

Oral Surgery -- Temporomandibular Joint Surgery Otoplasty Reconstructive and Plastic Surgery Rhinoplasty Sacral Nerve Neuromodulation Septoplasty Surgeries, regardless of place of service continued Spinal Surgeries including Fusion, Stabilization, Discectomy Uvulopalatopharyngoplasty/ Uvolopharyngoplasty

Veins (ablation, ligation, stripping, sclerotherapy) X-Stop: Spinal Surgery

Transplants All transplant evaluations and procedures, including but not limited to evaluation, transplant consult visits, HLA typing, donor search and transplant procedure

Part B – Appendix A J1572 FLEBOGAMMA INJECTION Effective Drug Effective Action Date (if Drug Description Drug Code Action Date (if Drug Description available) Code available) J1599 IVIG NON-LYOPHILIZED, NOS C9050 INJECTION, EMAPALUMAB-LZSG, 1 MG J1602 GOLIMUMAB FOR IV USE 1MG MOMETASONE FUROATE SINUS C9122 J1745 INJ INFLIXIMAB EXCL BIOSIMILR 10 MG IMPLANT 10 MCG SINUVA J1930 Remove 1/1/2021 INJECTION, LANREOTIDE, 1 MG J0129 ABATACEPT INJECTION J2323 NATALIZUMAB INJECTION J0178 AFLIBERCEPT INJECTION J2350 INJECTION OCRELIZUMAB 1 MG J0570 BUPRENORPHINE IMPLANT 74.2MG INJECTION, OCTREOTIDE, DEPOT J0585 INJECTION,ONABOTULINUMTOXINA FORM FOR INTRAMUSCULAR J2353 Remove 1/1/2021 INJECTION, 1 MG J0717 CERTOLIZUMAB PEGOL INJ 1MG J2357 INJECTION, OMALIZUMAB, 5 MG J0718 CERTOLIZUMAB PEGOL INJ INJECTION, PEGAPTANIB SODIUM, 0.3 INJECTION CRIZANLIZUMAB-TMCA 5 J0791 J2503 MG MG INJECTION, CORTICOTROPIN, UP TO 40 J2505 INJECTION, PEGFILGRASTIM, 6 MG

J0800 UNITS J2507 PEGLOTICASE INJECTION INJECTION LUSPATERCEPT-AAMT 0.25 J0896 MG J2778 RANIBIZUMAB INJECTION J2786 J0897 DENOSUMAB INJECTION INJECTION RESLIZUMAB 1MG J2796 J1300 ECULIZUMAB INJECTION ROMIPLOSTIM INJECTION INJECTION, SARGRAMOSTIM (CM-CSF), J2820 J1428 INJECTION ETEPLIRSEN 10 MG 50 MCG J1429 INJECTION GOLODIRSEN 10 MG INJECTION ROMOSOZUMAB-AQQG 1 J3111 Add MG J1442 INJ FILGRASTIM EXCL BIOSIMIL INJECT TRIAMCINOLONE ACETONIDE INJECTION, TBO-FILGRASTIM, 1 J1447 J3304 PF ER MS F 1 MG MICROGRAM USTEKINUMAB FOR SUBQ INJECTION 1 J1459 INJ IVIG PRIVIGEN 500 MG J3357 MG INJECTION IMMUNE GLOBULIN 100 J3380 INJECTION VEDOLIZUMAB 1 MG J1555 MG J3396 INJECTION, VERTEPORFIN, 0.1 MG J1556 INJ, IMM GLOB BIVIGAM, 500MG INJECTION FA INTRAVITREAL IMPL 0.01 J7311 J1557 GAMMAPLEX INJECTION MG INJECTION IMMUNE GLOBULIN J1558 J7312 DEXAMETHASONE INTRA IMPLANT XEMBIFY 100 MG INJECTION FA INTRAVITREAL IMPL 0.01 J7313 J1559 HIZENTRA INJECTION MG INJECTION FA INTRAVITREAL IMPL 0.01 J1561 GAMUNEX-C/GAMMAKED J7314 INJECTION; IMMUNE GLOBULIN 10%, 5 MG J1562 GRAMS HYALURONAN/DERIVATIVE DUROLANE J7318 FOR IA INJ 1 MG INJECTION, IMMUNE GLOBULIN, HYALURONAN/DERIVITIVE GENVISC J1566 INTRAVENOUS, LYOPHILIZED (E.G. P J7320 850 IA INJ 1 MG J1568 OCTAGAM INJECTION HYAL HYALGN SUPARTZ/VSCO-3 IA INJ- J1569 GAMMAGARD LIQUID INJECTION J7321 D

HYALURONAN/DRIV HYMOVIS IA INJ 1 Effective J7322 MG Drug Action Date (if Drug Description Effective Code Drug available) Action Date (if Drug Description Code INJECTION, FILGRASTIM-AAFI, available) Q5110 BIOSIMILAR, (NIVESTYM), 1 MICROGRAM J7324 ORTHOVISC INJ PER DOSE INJECTION, PEGFILGRASTIM-CBQV, J7325 SYNVISC OR SYNVISC-ONE Q5111 BIOSIMILAR, (UDENYCA), 0.5 MG J7326 GEL-ONE INJECTION TRASTUZUMAB-DTTB J7327 MONOVISC INJ PER DOSE Q5112 BIOSIMILAR 10 MG INJECTION TRASTUZUMAB-PKRB J7328 HYAL/DERIV GELSYN-3 IA INJ 0.1 MG Q5113 BIOSIMILAR 10 MG HYALURONAN/DERIVATIVE TRIVISC INJECTION TRASTUZUMAB-DKST

J7329 FOR IA INJ 1 MG Q5114 BIOSIMILAR 10 MG HYALURONAN/DERIVATIVE INJECTION RITUXIMAB-ABBS J7331 Q5115 SYNOJOYNT IA INJ 1 MG BIOSIMILAR 10 MG HYALURONAN/DERIVATIVE TRILURON J7332 INJECTION TRASTUZUMAB-QYYP IA INJ 1 MG Q5116 BIOSIMILAR 10 MG HYALURONAN/DERIVATIVE VISCO-3 IA J7333 INJECTION TRASTUZUMAB-ANNS INJ PER DOSE Q5117 BIOSIMILAR 10 MG MOMETASONE FUROATE SINUS J7401 Q5118 INJECTION, BEVACIZUMAB-BVZR, IMPLANT 10 MCG BIOSIMILAR, (ZIRABEV), 10 MG J9022 INJECTION ATEZOLIZUMAB 10 MG INJ RITUXIMAB-PVVR BIOSIMILAR Q5119 J9145 INJECTION DARATUMUMAB 10 MG RUXIENCE 10 MG INJ PEGFILGRASTIM-BMEZ BIOSIMLR Q5120 J9173 INJECTION DURVALUMAB 10 MG ZIEXTENZO 0.5 MG J9176 INJECTION ELOTUZUMAB 1MG INJ INFLIXIMAB-AXXQ BIOSIMILAR Q5121 J9308 INJECTION RAMUCIRUMAB 5 MG AVSOLA 10 MG INJECTION RITUXIMAB 10 MG AND Q9991 BUPRENORPH XR 100 MG OR LESS

J9311 HYALURONIDASE Q9992 BUPRENORPHINE XR OVER 100 MG J9312 INJECTION RITUXIMAB 10 MG Effective Drug Action Date (if Drug Description INJECTION TRASTUZUMAB EXCLUDES Code J9355 BIOSIMILAR 10 MG available) SPECIAL PROCESSED DRUGS - FDA INJECTION TRASTUZUMAB 10 MG AND 892 APPROVED GENE THERAPY J9356 HYALURONIDASE-OYSK LUTETIUM LU 177 DOTATATE INJECTION FAM-TRASTUZUMAB A9513 J9358 THERAPEUTIC 1 MCI DERUXTECAN-NXKI 1 MG KTE-C19 TO 200 M A ANTI-CD19 CAR C9035 INJECTION ARIPIPRAZOLE LAUROXIL 1 Q2041 POS T CE P TD C9036 MG TISAGENLECLEUCEL TO 600 M CAR- INJECTION PATISIRAN 0.1 MG Q2042 POS VI T CE PER TD C9037 Q2043 SIPLEUCEL-T AUTO CD54+ INJECTION RISPERIDONE 0.5 MG INJECTION, FILGRASTIM-SNDZ, INJECTION MOGAMULIZUMAB-KPKC 1 C9038 Q5101 BIOSIMILAR, (ZARXIO) MG INJECTION FREMANEZUMAB-VFRM 1 Q5103 INJECTION, INFLECTRA C9040 MG Q5104 INJECTION, RENFLEXIS C9043 INJECTION BEVACIZUMAB-AWWB INJECTION LEVOLEUCOVORIN 1 MG Q5107 BIOSIMILAR 10 MG C9044 INJECTION CEMIPLIMAB-RWLC 1 MG INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 INJECTION MOXETUMOMAB Q5108 C9045 MG PASUDOTOX-TDFK 0.01 MG INJECTION INFLIXIMAB-QBTX INJECTION, TAGRAXOFUSP-ERZS, 10 Q5109 C9049 BIOSIMILAR 10 MG MCG 1

Effective Effective Drug Drug Action Date (if Drug Description Action Date (if Drug Description Code Code available) available) C9050 INJECTION, EMAPALUMAB-LZSG, 1 MG J0517 INJECTION BENRALIZUMAB 1 MG C9051 INJECTION, OMADACYCLINE, 1 MG J0567 INJECTION CERLIPONASE ALFA 1 MG INJECTION, RAVULIZUMAB-CWVZ, 10 C9052 J0570 BUPRENORPHINE IMPLANT 74.2MG MG INJECTION CRIZANLIZUMAB-TMCA 1 J0584 INJECTION BUROSUMAB-TWZA 1 MG C9053 MG J0585 INJECTION,ONABOTULINUMTOXINA C9054 INJECTION LEFAMULIN XENLETA 1 MG Remove 1/1/2021 J0586 ABOBOTULINUMTOXINA C9055 INJECTION BREXANOLONE 1 MG J0587 INJ, RIMABOTULINUMTOXINB C9056 Remove 1/1/2021 INJECTION GIVOSIRAN 0.5 MG J0588 INCOBOTULINUMTOXIN A C9057 Remove 1/1/2021 INJECTION CETIRIZINE HCL 1 MG J0591 INJECTION DEOXYCHOLIC ACID 1 MG INJECTION PEGFILGRASTIM-BMEZ C9058 J0593 INJECTION LANADELUMAB-FLYO 1 MG Remove 1/1/2021 BIOSIMILAR 0.5 INJECTION TEPROTUMUMAB-TRBW 10 J0598 C-1 ESTERASE, CINRYZE C9061 MG INJECTION C-1 ESTERASE INHIBITOR 10 J0599 UNITS C9063 INJECTION EPTINEZUMAB-JJMR 1 MG MOMETASONE FUROATE SINUS J0604 CINACALCET ORAL 1 MG C9122 IMPLANT 10 MCG SINUVA J0606 INJECTION ETELCALCETIDE 0.1 MG INJ IMMUNE GLOBULIN BIVIGAM 500 INJECTION, CALCITONIN SALMON, UP C9130 J0630 Remove 1/1/2021 MG TO 400 UNITS C9133 FACTOR IX RECOMBINANT J0638 CANAKINUMAB INJECTION C9134 FACTOR XIII A-SUBUNIT RECOMB J0641 INJECTION LEVOLEUCOVORIN 0.5 MG INJECTION, LEVOLEUCOVORIN C9136 J0642 FACTOR VIII (ELOCTATE) (KHAPZORY), 0.5 MG UNCLASSIFIED DRUGS OR C9399 J0717 CERTOLIZUMAB PEGOL INJ 1MG BIOLOGICALS UNCLASSIFIED DRUGS OR J0718 CERTOLIZUMAB PEGOL INJ C9399 BIOLOGICALS J0775 COLLAGENASE, CLOST HIST INJ INJECTION CRIZANLIZUMAB-TMCA 5 J0129 ABATACEPT INJECTION J0791 MG J0135 INJECTION, ADALIMUMAB, 20 MG INJECTION, CORTICOTROPIN, UP TO 40 J0178 AFLIBERCEPT INJECTION J0800 UNITS J0179 INJECTION BROLUCIZUMAB-DBLL 1 INJECTION, DARBEPOETIN ALFA, 1 J0881 MG MICROGRAM (NON-ESRD USE) J0180 INJECTION, EPOETIN ALFA, (FOR NON- INJECTION, AGALSIDASE BETA, 1 MG J0885 ESRD USE), 1000 UNITS J0202 INJECTION ALEMTUZUMAB 1 MG J0888 EPOETIN BETA NON ESRD J0220 ALGLUCOSIDASE ALFA INJECTION J0894 INJECTION DECITABINE 1 MG J0221 LUMIZYME INJECTION INJECTION LUSPATERCEPT-AAMT 0.25 J0896 J0222 INJECTION PATISIRAN 0.1 MG MG J0223 INJECTION GIVOSIRAN 0.5 MG J0256 ALPHA 1 PROTEINASE INHIBITOR J0897 DENOSUMAB INJECTION INJECTION, DEXRAZOXANE HCL, PER J0257 J1190 GLASSIA INJECTION 250 MG INJECTION APOMORPHINE J0364 HYDROCHLORIDE 1 MG J1300 ECULIZUMAB INJECTION J1301 J0490 BELIMUMAB INJECTION INJECTION EDARAVONE 1 MG

Effective Effective Drug Drug Action Date (if Drug Description Action Date (if Drug Description Code Code available) available) INJECTION RAVULIZUMAB-CWVZ 10 J1303 J1745 INJ INFLIXIMAB EXCL BIOSIMILR 10 MG MG J1746 INJECTION IBALIZUMAB-UIYK 10 MG J1324 INJECTION, ENFUVIRTIDE, 1 MG J1786 IMUGLUCERASE INJECTION J1428 INJECTION ETEPLIRSEN 10 MG INSULIN FOR ADMINISTRATION J1429 INJECTION GOLODIRSEN 10 MG J1817 THROUGH DME (I.E., INSULIN PUMP) INJECTION, ETANERCEPT, 25 MG PER 50 UNITS J1438 (CODE MAY BE USED FOR MEDICARE J1930 INJECTION, LANREOTIDE, 1 MG WHEN DRUG AD J1931 INJECTION, LARONIDASE, 0.1 MG J1439 INJ FERRIC CARBOXYMALTOS 1MG J2170 Mecasermin injection J1442 INJ FILGRASTIM EXCL BIOSIMIL J1443 J2182 INJ FERRIC PRPP CIT SOL 0.1 MG IRON INJECTION MEPOLIZUMAB 1MG J1447 INJECTION, TBO-FILGRASTIM, 1 J2212 METHYLNALTREXONE INJECTION MICROGRAM INJECTION NALTREXONE DEPOT FORM J2315 J1458 INJECTION GALSULFASE 1 MG 1 MG J1459 INJ IVIG PRIVIGEN 500 MG J2323 NATALIZUMAB INJECTION INJECTION IMMUNE GLOBULIN 100 J2350 INJECTION OCRELIZUMAB 1 MG J1555 MG INJECTION, OCTREOTIDE, DEPOT J1556 INJ, IMM GLOB BIVIGAM, 500MG FORM FOR INTRAMUSCULAR J2353 INJECTION, 1 MG J1557 GAMMAPLEX INJECTION INJECTION IMMUNE GLOBULIN J2355 INJECTION, OPRELVEKIN, 5 MG J1558 XEMBIFY 100 MG J2357 INJECTION, OMALIZUMAB, 5 MG J1559 HIZENTRA INJECTION INJECTION, PAPAVERINE HCL, UP TO J2440 J1561 GAMUNEX-C/GAMMAKED 60 MG INJECTION; IMMUNE GLOBULIN 10%, 5 INJECTION, PEGAPTANIB SODIUM, 0.3 J1562 GRAMS J2503 MG INJECTION, IMMUNE GLOBULIN, J2505 INJECTION, PEGFILGRASTIM, 6 MG J1566 INTRAVENOUS, LYOPHILIZED (E.G. P J2507 PEGLOTICASE INJECTION J1568 OCTAGAM INJECTION J2562 PLERIXAFOR INJECTION J1569 GAMMAGARD LIQUID INJECTION J2778 RANIBIZUMAB INJECTION J1572 FLEBOGAMMA INJECTION J2783 INJECTION, RASBURICASE, 0.5 MG J2786 J1575 INJ IG/HYALURONIDASE 100 MG IG INJECTION RESLIZUMAB 1MG J2793 J1599 IVIG NON-LYOPHILIZED, NOS RILONACEPT INJECTION J2796 J1599 IVIG NON-LYOPHILIZED, NOS ROMIPLOSTIM INJECTION J2797 J1602 GOLIMUMAB FOR IV USE 1MG INJECTION ROLAPITANT 0.5 MG INJECTION, SARGRAMOSTIM (CM-CSF), J1628 J2820 INJECTION GUSELKUMAB 1 MG 50 MCG J1640 INJECTION, HEMIN, 1 MG J2840 INJ SEBELIPASE ALFA 1 MG INJECTION, DALTEPARIN SODIUM, PER J1645 J2940 2500 IU INJECTION, SOMATREM, 1 MG INJECTION, HISTRELIN ACETATE, 10 J2941 J1675 INJECTION, SOMATROPIN, 1 MG MICROGRAMS J3095 TELEVANCIN INJECTION J1743 IDURSULFASE INJECTION J3110 INJECTION, TERIPARATIDE, 10 MCG J1744 ICATIBANT INJECTION

Effective Effective Drug Drug Action Date (if Drug Description Action Date (if Drug Description Code Code available) available) INJECTION ROMOSOZUMAB-AQQG 1 J3111 J7188 INJECTION FACTOR VIII PER I.U. Add MG FACTOR VIIA (ANTIHEMOPHILIC INJECTION, TESTOSTERONE J3140 J7189 FACTOR, RECOMBINANT), PER 1 MICR SUSPENSION, UP TO 50 MG FACTOR VIII, (ANTI-HEMOPHILIC INJECTION, THYROTROPIN, UP TO 10 J7190 J3240 FACTOR (HUMAN)), PER I.U. I.U. J3245 J7191 INJECTION TILDRAKIZUMAB 1 MG FACTOR VIII (PORCINE) J3262 TOCILIZUMAB INJECTION J7192 FACTOR VIII RECOMBINANT NOS J3285 INJECTION, TREPROSTINIL, 1 MG FACTOR IX (ANTIHEMOPHILIC FACTOR, INJECT TRIAMCINOLONE ACETONIDE J7193 PURIFIED, NON-RECOMBINANT) PER J3304 PF ER MS F 1 MG I.U. INJECTION TRIPTORELIN EXTENDED- J3316 J7194 RELEASE 3.75 MG FACTOR IX, COMPLEX, PER I.U. USTEKINUMAB FOR SUBQ INJECTION 1 J7195 FACTOR IX RECOMBINANT NOS J3357 MG J7196 ANTITHROMBIN RECOMBINANT J3380 INJECTION VEDOLIZUMAB 1 MG J3385 J7197 VELAGLUCERASE ALFA ANTITHROMBIN III (HUMAN), PER I.U. J3396 INJECTION, VERTEPORFIN, 0.1 MG J7198 ANTI-INHIBITOR, PER I.U. INJECT TRIAMCINOLONE ACETONIDE HEMOPHILIA CLOTTING FACTOR, NOT J3397 J7199 PF ER MS F 1 MG OTHERWISE CLASSIFIED INJECTION VORETIGENE NEPARVOVEC- J3398 J7200 RZYL 1 B VEC G FACTOR IX RECOMBINAN RIXUBIS INJ AVSX-101-XIOI P-TX TO 5X10^15 J7201 INJ FACTOR IX FC FUS PROTEIN PER IU J3399 VCTR GNOMS J7202 FACTOR IX IDELVION INJ J3490 UNCLASSIFIED DRUGS J7203 INJECTION FACTOR IX J3590 UNCLASSIFIED BIOLOGICS GLYCOPEGYLATED 1 IU UNCLASS RX/BIOLOGICAL USED FOR INJ FAC VIII ANTIHEM FAC J3591 J7204 ESRD ON DIALYSIS GLYCOPEGYLATD-EXEI P-IU INJ COAGULATION FACTOR XA J7169 J7207 FACTOR VIII PEGYLATED RECOMB INACTIVATED-ZHZO 10 MG INJECTION FACTOR VIII PEGYLATED- INJECTION EMICIZUMAB-KXWH 0.5 J7208 J7170 AUCL 1 IU MG J7209 FACTOR VIII NUWIQ RECOMB 1IU J7175 INJ FACTOR X (HUMAN) 1IU INJECTION FA INTRAVITREAL IMPL 0.01 INJECTION HUMAN FIBRINOGEN J7311 J7177 MG CONCENTRATE 1 MG J7312 DEXAMETHASONE INTRA IMPLANT J7179 INJECTION FA INTRAVITREAL IMPL 0.01 VONVENDI INJ 1 IU VWF:RCO J7313 MG J7180 FACTOR XIII ANTI-HEM FACTOR INJECTION FA INTRAVITREAL IMPL 0.01 J7314 J7181 FACTOR XIII RECOMB A-SUBUNIT MG HYALURONAN/DERIVATIVE DUROLANE J7182 FACTOR VIII RECOMB NOVOEIGHT J7318 FOR IA INJ 1 MG J7183 WILATE INJECTION HYALURONAN/DERIVITIVE GENVISC J7185 XYNTHA INJ J7320 850 IA INJ 1 MG HYAL HYALGN SUPARTZ/VSCO-3 IA INJ- J7186 ANTIHEMOPHILIC VIII/VWF COMP J7321 D INJECTION VON WILLEBRAND FACTOR HYALURONAN/DRIV HYMOVIS IA INJ 1 J7187 COMPLEX HUMAN RISTOCETIN J7322 MG COFACTOR PER IV

Effective Effective Drug Drug Action Date (if Drug Description Action Date (if Drug Description Code Code available) available) J7323 EUFLEXXA INJ PER DOSE J9047 INJECTION, CARFILZOMIB, 1 MG J7324 ORTHOVISC INJ PER DOSE J9050 CARMUSTINE INJECTION J7325 SYNVISC OR SYNVISC-ONE J9055 INJECTION, CETUXIMAB, 10 MG J7326 GEL-ONE J9057 INJECTION COPANLISIB 1 MG INJECTION CALASPARGASE PEGOL- J7327 MONOVISC INJ PER DOSE J9118 Add MKNL 10 UNITS J7328 HYAL/DERIV GELSYN-3 IA INJ 0.1 MG J9145 INJECTION DARATUMUMAB 10 MG HYALURONAN/DERIVATIVE TRIVISC INJECTION LIPOSOMAL 1 MG DNR AND J7329 FOR IA INJ 1 MG J9153 2.27 MG CA HYALURONAN/DERIVATIVE J7331 SYNOJOYNT IA INJ 1 MG J9173 INJECTION DURVALUMAB 10 MG HYALURONAN/DERIVATIVE TRILURON J7332 J9176 INJECTION ELOTUZUMAB 1MG IA INJ 1 MG INJECTION ENFORTUMAB VEDOTIN- HYALURONAN/DERIVATIVE VISCO-3 IA J9177 J7333 EJFV 0.25 MG INJ PER DOSE INJ GEMCITABINE HYDROCHLORIDE MOMETASONE FUROATE SINUS J9198 J7401 INFUGEM 100 MG IMPLANT 10 MCG J9199 INJECTION GEMCITABINE HCL J7518 MYCOPHENOLIC ACID, ORAL, 180 MG INFUGEM 200 MG INJ GEMTUZUMAB OZOGAMICIN 0.1 J7527 ORAL EVEROLIMUS J9203 MG REVEFENACIN INHAL SOL J7677 NONCOMPND ADM DME 1 MCG J9205 INJ IRINOTECAN LIPOSOME 1 MG INJECTION, INTERFERON ALFACON-1, J7686 TREPROSTINIL, NON-COMP UNIT J9212 RECOMBINANT, 1 MCG J8499 Remove 1/1/2021 NOS DRUG, ORAL INTERFERON, ALFA-2A, J9213 J8565 GEFITINIB, ORAL, 250 MG RECOMBINANT, 3 MILLION UNITS INTERFERON, ALFA-N3, (HUMAN J8650 J9215 Nabilone oral LEUKOCYTE DERIVED), 250,000 IU INTERFERON, GAMMA 1-B, 3 MILLION J8705 J9216 TOPOTECAN ORAL UNITS J8999 NOS PRES DRUG, ORAL, CHEMO J9225 J9015 ALDESLEUKIN/SINGLE USE VIAL HISTRELIN IMPLANT, 50 MG J9017 ARSENIC TRIOXIDE, 1MG J9226 SUPPRELIN LA IMPLANT J9019 ERWINAZE INJECTION J9228 J9022 INJECTION ATEZOLIZUMAB 10 MG IPILIMUMAB INJECTION INJECTION INOTUZUMAB J9023 INJECTION AVELUMAB 10 MG J9229 OZOGAMICIN 0.1 MG J9027 INJECTION, CLOFARABINE, 1 MG INJECTION MELPHALAN EVOMELA 1 J9246 J9034 INJ. BENDEKA 1 MG MG INJECTION BENDAMUSTINE J9036 J9261 INJECTION NELARABINE 50 MG HYDROCHLORIDE 1 MG J9262 INJECTION BLINATUMOMAB 1 INJ, OMACETAXINE MEP, 0.01MG J9039 INJECTION, PACLITAXEL PROTEIN- MICROGRAM J9264 BOUND PARTICLES, 1 MG J9041 INJECTION BORTEZOMIB 0.1 MG J9266 PEGASPARGASE/SINGL DOSE VIAL J9042 BRENTUXIMAB VEDOTIN INJ J9271 INJECTION PEMBROLIZUMAB 1 MG J9043 CABAZITAXEL INJECTION J9285 INJECTION OLARATUMAB 10 MG J9044 INJECTION BORTEZOMIB NOS 0.1 MG

Effective Effective Drug Drug Action Date (if Drug Description Action Date (if Drug Description Code Code available) available) Q3027 J9299 INJ BETA INTERFERON IM 1 MCG INJECTION NIVOLUMAB 1 MG Q4074 ILOPROST NON-COMP UNIT DOSE J9301 OBINUTUZUMAB INJ INJECTION, FILGRASTIM-SNDZ, J9303 PANITUMUMAB INJECTION Q5101 BIOSIMILAR, (ZARXIO) J9305 INJECTION, PEMETREXED, 10 MG Q5103 INJECTION, INFLECTRA J9306 INJECTION, PERTUZUMAB, 1 MG Q5104 INJECTION, RENFLEXIS J9308 INJECTION RAMUCIRUMAB 5 MG INJ EPOETIN ALFA-EPBX, BIOSIMILAR, J9309 INJECTION POLATUZUMAB VEDOTIN- (RETACRIT) (FOR NON-ESRD USE), PIIQ 1 MG Q5106 1000 UNITS INJECTION RITUXIMAB 10 MG AND INJECTION BEVACIZUMAB-AWWB J9311 HYALURONIDASE Q5107 BIOSIMILAR 10 MG J9312 INJECTION RITUXIMAB 10 MG INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 Q5108 J9325 INJ TALIMOGENE LAHERPAREPVEC MG INJECTION INFLIXIMAB-QBTX J9352 Q5109 INJECTION TRABECTEDIN 0.1MG BIOSIMILAR 10 MG J9354 INJ, ADO-TRASTUZUMAB EMT 1MG INJECTION, FILGRASTIM-AAFI, INJECTION TRASTUZUMAB EXCLUDES Q5110 BIOSIMILAR, (NIVESTYM), 1 J9355 BIOSIMILAR 10 MG MICROGRAM INJECTION TRASTUZUMAB 10 MG AND INJECTION, PEGFILGRASTIM-CBQV, Q5111 J9356 HYALURONIDASE-OYSK BIOSIMILAR, (UDENYCA), 0.5 MG INJECTION FAM-TRASTUZUMAB INJECTION TRASTUZUMAB-DTTB J9358 DERUXTECAN-NXKI 1 MG Q5112 BIOSIMILAR 10 MG INJECTION TRASTUZUMAB-PKRB J9395 INJECTION, FULVESTRANT, 25 MG Q5113 BIOSIMILAR 10 MG J9400 INJECTION TRASTUZUMAB-DKST INJ, ZIV-AFLIBERCEPT, 1MG Q5114 BIOSIMILAR 10 MG NOT OTHERWISE CLASSIFIED, J9999 INJECTION RITUXIMAB-ABBS ANTINEOPLASTIC DRUGS Q5115 BIOSIMILAR 10 MG NOT OTHERWISE CLASSIFIED, INJECTION TRASTUZUMAB-QYYP J9999 ANTINEOPLASTIC DRUGS Q5116 BIOSIMILAR 10 MG Q0138 FERUMOXYTOL, NON-ESRD INJECTION TRASTUZUMAB-ANNS INJECTION, SERMORELIN ACETATE, 1 Q5117 BIOSIMILAR 10 MG Q0515 MICROGRAM Q5118 INJECTION, BEVACIZUMAB-BVZR, Q2026 RADIESSE INJECTION BIOSIMILAR, (ZIRABEV), 10 MG INJ RITUXIMAB-PVVR BIOSIMILAR Q2027 Q5119 SCULPTRA INJECTION RUXIENCE 10 MG Q2028 INJ PEGFILGRASTIM-BMEZ BIOSIMLR INJ, SCULPTRA, 0.5MG Q5120 KTE-C19 TO 200 M A ANTI-CD19 CAR ZIEXTENZO 0.5 MG INJ INFLIXIMAB-AXXQ BIOSIMILAR Q2041 POS T CE P TD Q5121 TISAGENLECLEUCEL TO 600 M CAR- AVSOLA 10 MG Q2042 POS VI T CE PER TD Q9991 Q2043 SIPLEUCEL-T AUTO CD54+ BUPRENORPH XR 100 MG OR LESS Q9992 Q2050 DOXORUBICIN INJ 10MG BUPRENORPHINE XR OVER 100 MG INJECTION, INTERFERON BETA-1A, 11 INJECTION, PEGYLATED INTERFERON Q3025 S0145 MCG FOR INTRAMUSCULAR USE ALFA-2A, 180 MCG PER ML INJECTION, INTERFERON BETA-1A, 11 J9119 CEMIPLIMAB-RWLC Q3026 MCG FOR SUBCUTANEOUS USE J9204 MOGAMULIZUMAB - KPKC

Effective Drug Action Date (if Drug Description Code available) J9269 TAGRAXOFUSP-ERZS

J9313 MOXETUMOMAB PASUDOTOX-TDFK J9179 ERIBULIN MESYLATE INJECTION