Authorization Requirements for Medications Under the Medical Benefit HCPC/MOD Marketplace BRAND NAME LONG DESCRIPTION SHORT DESCRIPTION Limits Rabies Immune Globulin 90375 No Auth. Required HyperRab Rabies Immune Globulin (Human) (Human) Up to 5 90378 Auth Required Synagis Palivizumab Synagis treatments Imovax Rabies vaccine, for intramuscular Rabies vaccine, for 90675 No Auth. Required Rabavert use (Code price is per 1 mL) intramuscular use Maximum 2 units Pfizer-Biontech Covid-19 Must be billed 91300 No Auth. Required Pfizer COVID-19 Vaccine SARSCOV2 VAC 30MCG/0.3ML IM Vaccine with 0001A or 0002A

Maximum 2 units Must be billed 91301 No Auth. Required Moderna COVID-19 Vaccine SARSCOV2 VAC 100MCG/0.5ML IM Moderna Covid-19 Vaccine with 0011A or 0012A

Postpartum Maternal Newborn Postpartum Maternal 4 Units Within 180 99501 No Auth. Required Assessment Service Newborn Assessment Service days 4 Units Within 180 99502 No Auth. Required Newborn Assessment Newborn Assessment days Home Nursing Visit for Medication Home Nursing Visit for 99506 Auth Required Administration Medication Administration 17Alpha- 17Alpha-hydroxyprogesterone hydroxyprogesterone 99600 No Auth. Required Caproate (17P) Administration Caproate (17P) Nursing Service Administration Nursing Service Home infusion/specialty drug Home infusion/specialty drug Up to 2 hours per 99601 No Auth. Required administration, per visit (up to 2 administration, per visit (up day hours) to 2 hours) Home infusion/specialty drug Home infusion/specialty drug administration, per visit (up administration, per visit (up to 2 to 2 hours); each additional hours); each additional hour (List hour (List separately in Up to 2 hours per 99602 No Auth. Required separately in addition to code addition to code 99601 for day 99601 for primary procedure) (Use primary procedure) (Use 99602 in conjunction with 99601) 99602 in conjunction with 99601) Maximum 1 Pfizer-Biontech Covid-19 Pfizer COVID-19 Vaccine administration 0001A No Auth. Required ADM SARSCOV2 30MCG/0.3ML 1ST Vaccine Administration – Administration First Dose and must be billed First Dose with 91300 Maximum 1 Pfizer-Biontech Covid-19 Pfizer COVID-19 Vaccine ADM SARSCOV2 30MCG/0.3ML administration 0002A No Auth. Required Vaccine Administration – Administration Second Dose 2ND and must be billed Second Dose with 91300 Maximum 1 Moderna COVID-19 Vaccine ADM SARSCOV2 Moderna Covid-19 Vaccine administration 0011A No Auth. Required Administration First Dose 100MCG/0.5ML1ST Administration – First Dose and must be billed with 91301 Maximum 1 Moderna Covid-19 Vaccine Moderna COVID-19 Vaccine ADM SARSCOV2 administration 0012A No Auth. Required Administration – Second Administration Second Dose 100MCG/0.5ML2ND and must be billed Dose with 91301 Sterile water, saline, and/or A4216 No Auth. Required Sterile water Sterile water dextrose, diluent/flush, 10 mL

A4221 No Auth. Required Supp non-insulin inf cath/wk Supp non-insulin inf cath/wk A4222 No Auth. Required Infusion supplies with pump Infusion supplies with pump A4223 No Auth. Required Infusion supplies w/o pump Infusion supplies w/o pump A4224 No Auth. Required Supply insulin inf cath/wk Supply insulin inf cath/wk Lutetium Iu, dotatete, therapeutic, A9513 Auth Required Lutathera lutetium Iu 177 1 millicurie A9606 Auth Required Xofigo Radium Ra 223 dichloride Xofigo

Effective 7/1/2021 Parenteral nutrition solution: B4164 No Auth. Required carbohydrates (dextrose), 50% or Parenteral 50% dextrose solu less (500 ml = 1 unit) - home mix Parenteral nutrition solution; amino B4168 No Auth. Required acid, 3.5%, (500 ml = 1 unit) - home Parenteral sol amino acid 3. mix Parenteral nutrition solution; amino B4172 No Auth. Required acid, 5.5% through 7%, (500 ml = 1 Parenteral sol amino acid 5. unit) - home mix Parenteral nutrition solution; amino B4176 No Auth. Required acid, 7% through 8.5%, (500 ml = 1 Parenteral sol amino acid 7- unit) - home mix Parenteral nutrition solution: amino B4178 No Auth. Required acid, greater than 8.5% (500 ml = 1 Parenteral sol amino acid > unit) - home mix Parenteral nutrition solution; carbohydrates (dextrose), greater B4180 No Auth. Required Parenteral sol carb > 50% than 50% (500 ml = 1 unit) - home mix Clinolipid, Nutrilipid, Parenteral nutrition solution, not B4185 No Auth. Required Pn soln nos 10 grams lipids Smolipid, Intralipid otherwise specified, 10 grams lipids B4187 No Auth. Required Omegaven Omegaven, 10 grams lipids Omegaven, 10 grams lipids

Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, B4189 No Auth. Required Parenteral sol amino acid & trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix

Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, B4193 No Auth. Required Parenteral sol 52-73 gm prot trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix

Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, B4197 No Auth. Required Parenteral sol 74-100 gm pro trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix

Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, B4199 No Auth. Required Parenteral sol > 100gm prote trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix

Parenteral nutrition; additives B4216 No Auth. Required (vitamins, trace elements, heparin, Parenteral nutrition additiv electrolytes), home mix, per day

Parenteral nutrition supply kit; B4220 No Auth. Required Parenteral supply kit premix premix, per day Parenteral nutrition supply kit; B4222 Auth Required Parenteral supply kit homemi home mix, per day Parenteral nutrition administration B4224 No Auth. Required Parenteral administration ki kit, per day Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, B5000 No Auth. Required trace elements, and vitamins, Parenteral sol renal-amirosy including preparation, any strength, renal-aminosyn-rf, nephramine, renamine-premix

Effective 7/1/2021 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, B5100 No Auth. Required Parenteral solution hepatic trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix

Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, B5200 No Auth. Required trace elements, and vitamins, Parenteral sol hepatic fream including preparation, any strength, stress-branch chain amino acids- freamine-hbc-premix Parenteral nutrition infusion pump, B9004 Auth Required Parenteral infus pump portab portable Parenteral nutrition infusion pump, B9006 Auth Required Parenteral infus pump statio stationary

B9999 Auth Required Noc for parenteral supplies Parenteral supp not othrws c C9014 Auth Required Brineura Injection, cerliponase alfa, 1 mg Injection, cerliponase alfa Injection, c-1 esterase inhibitor C9015 Auth Required Haegarda C-1 esterase, haegarda (human), haegarda, 10 units Injection, triptorelin extended C9016 Auth Required Triptodur Inj, triptorelin ext rel release, 3.75 mg Injection, liposomal, 1 mg C9024 Auth Required Vyxeos daunorubicin and 2.27 mg Inj, daunorubicin-cytarabine cytarabine Injection, inotuzumab ozogamicin, C9028 Auth Required Besponsa Inj. inotuzumab ozogamicin 0.1 mg C9029 Pharmacy Benefit Tremfya Injection, guselkumab, 1 mg Injection, guselkumab Injection, fosnetupitant 235 mg and C9033 Auth Required Akynzeo Inj, akynzeo palonosetron 0.25 mg Cocaine hydrochloride nasal C9046 Auth Required Cocaine, Goprelto solution for topical administration, Cocaine hcl nasal solution 1 mg C9047 Auth Required Cablivi Injection, caplacizumab-yhdp, 1 mg Injection, caplacizumab-yhdp Injection, pantoprazole sodium, per C9113 No Auth. Required Protonix Inj pantoprazole sodium, via vial Mometasone furoate sinus C9122 Auth Required Sinuva Mometasone furoate (sinuva) implant, 10 micrograms (sinuva) Injection, factor viii, (antihemophilic C9141 Auth Required Jivi factor, recombinant), pegylated- Factor viii pegylated-aucl aucl (jivi), 1 i.u.

C9248 No Auth. Required Cleviprex Injection, clevidipine butyrate, 1 mg Inj, clevidipine butyrate C9254 No Auth. Required Vimpat Injection, lacosamide, 1 mg Injection, lacosamide C9257 Auth Required Avastin Injection, bevacizumab, 0.25 mg Bevacizumab injection Lidocaine 70 mg/tetracaine 70 mg, C9285 No Auth. Required Synera Patch, lidocaine/tetracaine per patch Injection, bupivacaine liposome, 1 C9290 No Auth. Required Exparel Inj, bupivacaine liposome mg C9293 No Auth. Required Voraxaze Injection, glucarpidase, 10 units Injection, glucarpidase C9399 Auth Required Unclassified code Unclassified drugs or biologicals Unclassified drugs or biolog C9460 No Auth. Required Kengreal Injection, cangrelor, 1 mg Injection, cangrelor C9462 Auth Required Baxdela Injection, delafloxacin, 1 mg Injection, delafloxacin Injection, conivaptan hydrochloride, C9488 Auth Required Vaprisol Conivaptan hcl 1 mg

Effective 7/1/2021 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified G2082 Auth Required Spravato Visit esketamine 56m or less health care professional and provision of up to 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation

Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified G2083 Auth Required Spravato Visit esketamine, > 56m health care professional and provision of greater than 56 mg esketamine nasal self- administration, includes 2 hours post-administration observation

J0121 Auth Required Nuzyra Injection, omadacycline, 1 mg Inj., omadacycline, 1 mg J0122 Auth Required Xerava Injection, eravacycline, 1 mg Inj., eravacycline, 1 mg Self-administered: Injection, abatacept, 10 mg (code 4 units per 28 may be used for medicare when days J0129 Auth Required Orencia drug administered under the direct Abatacept injection supervision of a physician, not for Infusion: 100 units use when drug is self administered) per 28 days J0131 No Auth. Required Ofirmev Injection, acetaminophen, 10 mg Acetaminophen injection J0132 No Auth. Required Mucomyst Injection, acetylcysteine, 100 mg Acetylcysteine injection J0133 No Auth. Required Zovirax Injection, acyclovir, 5 mg Acyclovir injection J0135 Pharmacy Benefit Humira Injection, adalimumab, 20 mg Adalimumab injection 4 per 28 days Injection, adenosine, 1 mg (not to J0153 No Auth. Required Adenosine be used to report any adenosine Adenosine inj 1mg phosphate compounds) Injection, adrenalin, epinephrine, J0171 No Auth. Required Epinephrine Adrenalin epinephrine inject 0.1 mg J0178 Auth Required Eylea Injection, aflibercept, 1 mg Aflibercept injection Injection, brolucizumab-dbll, J0179 Auth Required Beovu Inj, brolucizumab-dbll, 1 mg 1 mg J0180 Auth Required Fabrazyme Injection, agalsidase beta, 1 mg Agalsidase beta injection J0185 Auth Required Cinvanti Injection, aprepitant, 1 mg Inj., aprepitant, 1 mg J0202 Auth Required Lemtrada Injection, alemtuzumab, 1 mg Injection, alemtuzumab J0205 Auth Required Injection, alglucerase, per 10 units Alglucerase injection J0207 No Auth. Required Ethyol Injection, amifostine, 500 mg Amifostine J0215 Auth Required Injection, alefacept, 0.5 mg Alefacept Injection, alglucosidase alfa, 10 mg, J0220 Auth Required Alglucosidase alfa injection not otherwise specified Injection, alglucosidase alfa, J0221 Auth Required Lumizyme Lumizyme injection (lumizyme), 10 mg J0222 Auth Required Onpattro Injection, patisiran, 0.1 mg Inj., patisiran, 0.1 mg J0223 Auth Required Givlaari Inj givosiran 0.5 mg Injection, givosiran, 0.5 mg

Injection, alpha 1 proteinase 60mg/kg once J0256 Auth Required Aralast NP Prolastin-C inhibitor (human), not otherwise Alpha 1 proteinase inhibitor weekly specified, 10 mg

Injection, alpha 1 proteinase J0257 No Auth. Required Glassia Glassia injection inhibitor (human), (glassia), 10 mg

Effective 7/1/2021 Injection, alprostadil, 1.25 mcg (code may be used for medicare when drug administered under the J0270 No Auth. Required Edex Alprostadil for injection direct supervision of a physician, not for use when drug is self administered) Alprostadil urethral suppository (code may be used for medicare when drug administered under the J0275 No Auth. Required Muse Alprostadil urethral suppos direct supervision of a physician, not for use when drug is self administered)

J0278 No Auth. Required Amikacin Injection, amikacin sulfate, 100 mg Amikacin sulfate injection Injection, aminophyllin, up to 250 J0280 No Auth. Required Aminophylline Aminophyllin 250 mg inj mg Injection, amiodarone J0282 No Auth. Required Amiodarone Amiodarone hcl hydrochloride, 30 mg J0285 No Auth. Required Amphotericin B Injection, amphotericin b, 50 mg Amphotericin b Injection, amphotericin b lipid J0287 No Auth. Required Abelcet Amphotericin b lipid complex complex, 10 mg Injection, amphotericin b liposome, J0289 No Auth. Required Ambisome Amphotericin b liposome inj 10 mg

J0290 No Auth. Required Ampiciliin Injection, ampicillin sodium, 500 mg Ampicillin 500 mg inj J0291 No Auth. Required Zemdri Injection, plazomicin, 5 mg Inj., plazomicin, 5 mg Injection, ampicillin J0295 No Auth. Required Unasyn sodium/sulbactam sodium, per 1.5 Ampicillin sulbactam 1.5 gm gm Injection, amobarbital, up to 125 J0300 No Auth. Required Amytal Amobarbital 125 mg inj mg Injection, succinylcholine chloride, J0330 No Auth. Required Succinylcholine Succinycholine chloride inj up to 20 mg J0348 No Auth. Required Eraxis Injection, anidulafungin, 1 mg Anidulafungin injection Injection, hydralazine hcl, up to 20 J0360 No Auth. Required Apresoline Hydralazine hcl injection mg Injection, apomorphine J0364 Auth Required Apokyn Apomorphine hydrochloride hydrochloride, 1 mg Injection, aripiprazole, extended J0401 No Auth. Required Abilify Maintena Inj aripiprazole ext rel 1mg release, 1 mg J0456 No Auth. Required Zithromax Injection, azithromycin, 500 mg Azithromycin J0461 No Auth. Required Atropine Injection, atropine sulfate, 0.01 mg Atropine sulfate injection J0470 No Auth. Required Ban in Oil Injection, dimercaprol, per 100 mg Dimecaprol injection J0475 No Auth. Required Lioresal Injection, baclofen, 10 mg Baclofen 10 mg injection Injection, baclofen, 50 mcg for J0476 No Auth. Required Lioresal IT Baclofen intrathecal trial intrathecal trial J0480 No Auth. Required Simulect Injection, basiliximab, 20 mg Basiliximab J0485 No Auth. Required Nulojix Injection, belatacept, 1 mg Belatacept injection J0490 Auth Required Benlysta Injection, belimumab, 10 mg Belimumab injection Injection, dicyclomine hcl, up to 20 J0500 No Auth. Required Bentyl Dicyclomine injection mg Injection, benztropine mesylate, per J0515 No Auth. Required Cogentin Inj benztropine mesylate 1 mg J0517 Auth Required Fasenra Injection, benralizumab, 1 mg Inj., benralizumab, 1 mg Injection, penicillin g benzathine PenG benzathine/procaine J0558 No Auth. Required Bicillin C-R and penicillin g procaine, 100,000 inj units Injection, penicillin g benzathine, J0561 No Auth. Required Bicillin L-A Penicillin g benzathine inj 100,000 units J0565 No Auth. Required Zinplava Injection, bezlotoxumab, 10 mg Inj, bezlotoxumab, 10 mg J0567 Auth Required Brineura Injection, cerliponase alfa, 1 mg Inj., cerliponase alfa 1 mg 1 unit for 6 Buprenorphine implant months with a 6 J0570 Auth Required Probuphine Buprenorphine implant, 74.2 mg 74.2mg month reauth only J0571 Pharmacy Benefit Subutex Buprenorphine, oral, 1 mg Buprenorphine oral 1mg

Effective 7/1/2021 Buprenorphine/naloxone, oral, less Bupren/nal up to 3mg J0572 Pharmacy Benefit Suboxone than or equal to 3 mg bupreno buprenorphine Buprenorphine/naloxone, oral, Bupren/nal 3.1 to 6mg J0573 Pharmacy Benefit Suboxone greater than 3 mg, but less than or bupren equal to 6 mg buprenorphine Buprenorphine/naloxone, oral, Bupren/nal 6.1 to 10mg J0574 Pharmacy Benefit Suboxone greater than 6 mg, but less than or bupre equal to 10 mg buprenorphine Buprenorphine/naloxone, oral, Bupren/nal over 10mg J0575 Pharmacy Benefit Suboxone greater than 10 mg buprenorphine bupreno J0583 No Auth. Required Angiomax Injection, bivalirudin, 1 mg Bivalirudin Injection, burosumab-twza J0584 Auth Required Crysvita Injection, burosumab-twza 1 mg 1m Injection, onabotulinumtoxin a, 1 Injection,onabotulinumtoxin J0585 Auth Required Botox unit a Injection, abobotulinumtoxin a, 5 J0586 Auth Required Dysport Abobotulinumtoxin a units Injection, rimabotulinumtoxin b, J0587 Auth Required Myobloc Inj, rimabotulinumtoxin b 100 units Injection, incobotulinumtoxin a, 1 J0588 Auth Required Xeomin Incobotulinumtoxin a unit Injection, deoxycholic acid, 1 J0591 Auth Required Kybella Inj deoxycholic acid, 1 mg mg Injection, buprenorphine Buprenorphine J0592 No Auth. Required Buprenex hydrochloride, 0.1 mg hydrochloride Injection, lanadelumab-flyo, 1 mg (code may be used for medicare when drug administered under J0593 Auth Required Takhzyro Inj., lanadelumab-flyo, 1 mg direct supervision of a physician, not for use when drug is self- administered) J0594 No Auth. Required Busulfex injection, busulfan, 1 mg Busulfan injection Injection, butorphanol tartrate, 1 J0595 No Auth. Required Stadol Butorphanol tartrate 1 mg mg Injection, c1 esterase inhibitor J0596 Auth Required Ruconest Injection, ruconest 56mL per 30 days (recombinant), ruconest, 10 units Adult: 50mL per 30 days Injection, c-1 esterase inhibitor J0597 Auth Required Berinert C-1 esterase, berinert (human), berinert, 10 units Pediatric: 30mL per 30 days

Injection, c-1 esterase inhibitor J0598 Auth Required Cinryze C-1 esterase, cinryze (human), cinryze, 10 units Injection, c-1 esterase inhibitor J0599 Auth Required Haegarda Inj., haegarda 10 units (human), (haegarda), 10 units Calcium Disodium Injection, edetate calcium J0600 No Auth. Required Edetate calcium disodium inj Versenate disodium, up to 1000 mg Cinacalcet, oral, 1 mg, (for esrd on J0604 No Auth. Required Sensipar Cinacalcet, esrd on dialysis dialysis) J0606 Auth Required Parsabiv Injection, etelcalcetide, 0.1 mg Inj, etelcalcetide, 0.1 mg Injection, calcium gluconate, per 10 J0610 No Auth. Required Calcium Gluconate Calcium gluconate injection ml Injection, calcitonin salmon, up to J0630 No Auth. Required Miacalcin Calcitonin salmon injection 400 units J0636 No Auth. Required Calcitrol Injection, calcitriol, 0.1 mcg Inj calcitriol per 0.1 mcg Injection, caspofungin acetate, 5 J0637 No Auth. Required Cancidas Caspofungin acetate mg 2 units per 28 J0638 Pharmacy Benefit Ilaris Injection, canakinumab, 1 mg Canakinumab injection days Injection, leucovorin calcium, per J0640 No Auth. Required Leucovorin Calcium Leucovorin calcium injection 50 mg Injection, levoleucovorin, not J0641 No Auth. Required Fusilev Inj levoleucovorin nos 0.5mg otherwise specified, 0.5 mg Injection, levoleucovorin J0642 Auth Required Khapzory Injection, khapzory, 0.5 mg (khapzory), 0.5 mg

Effective 7/1/2021 Injection, mepivacaine J0670 No Auth. Required Carbocaine Inj mepivacaine hcl/10 ml hydrochloride, per 10 ml

J0690 No Auth. Required Kefzol Injection, cefazolin sodium, 500 mg Cefazolin sodium injection J0691 Auth Required Xenleta Inj lefamulin 1 mg Injection, lefamulin, 1 mg Injection, cefepime hydrochloride, J0692 No Auth. Required Maxipime Cefepime hcl for injection 500 mg J0693 Auth Required Fetroja Injection, cefiderocol, 5 mg Inj., cefiderocol, 5 mg J0694 No Auth. Required Cefoxitin Injection, cefoxitin sodium, 1 gm Cefoxitin sodium injection Injection, ceftolozane 50 mg and J0695 No Auth. Required Zerbaxa Inj ceftolozane tazobactam tazobactam 25 mg Injection, ceftriaxone sodium, per J0696 No Auth. Required Rocephil Ceftriaxone sodium injection 250 mg Injection, sterile cefuroxime J0697 No Auth. Required Zinacef Sterile cefuroxime injection sodium, per 750 mg Injection, cefotaxime sodium, per J0698 No Auth. Required Claforan Cefotaxime sodium injection gm Injection, betamethasone acetate 3 Betamethasone acet&sod J0702 No Auth. Required Celestone Soluspan mg and betamethasone sodium phosp phosphate 3 mg J0706 No Auth. Required Cafcit Injection, caffeine citrate, 5 mg Caffeine citrate injection J0712 No Auth. Required Teflaro Injection, ceftaroline fosamil, 10 mg Ceftaroline fosamil inj J0713 No Auth. Required Fortaz Tazicef Injection, ceftazidime, per 500 mg Inj ceftazidime per 500 mg Injection, ceftazidime and J0714 Auth Required Avycaz Ceftazidime and avibactam avibactam, 0.5 g/0.125 g Injection, centruroides immune J0716 No Auth. Required Anascorp Centruroides immune f(ab) f(ab)2, up to 120 milligrams Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the 1200 units per 28 J0717 Auth Required Cimzia Certolizumab pegol inj 1mg direct supervision of a physician, days not for use when drug is self administered) Injection, chloramphenicol sodium Chloramphenicol sodium J0720 No Auth. Required Chloramphenicol succinate, up to 1 gm injec Injection, chorionic gonadotropin, Chorionic J0725 Auth Required Novarel Pregnyl per 1,000 usp units gonadotropin/1000u Injection, clonidine hydrochloride, 1 J0735 No Auth. Required Duraclon Clonidine hydrochloride mg J0740 No Auth. Required Cidofovir Injection, cidofovir, 375 mg Cidofovir injection Injection, imipenem 4 mg, J0742 Auth Required Recarbrio Inj imip 4 cilas 4 releb 2mg cilastatin 4 mg and relebactam 2 mg Injection, cilastatin sodium; J0743 No Auth. Required Timentin Cilastatin sodium injection imipenem, per 250 mg Injection, ciprofloxacin for J0744 No Auth. Required Cipro Ciprofloxacin iv intravenous infusion, 200 mg Injection, colistimethate sodium, up J0770 No Auth. Required Coly-Mycin M Colistimethate sodium inj to 150 mg Injection, collagenase, clostridium J0775 Auth Required Xiaflex Collagenase, clost hist inj histolyticum, 0.01 mg Injection, prochlorperazine, up to J0780 No Auth. Required Compazine Prochlorperazine injection 10 mg Injection, crizanlizumab- J0791 Auth Required Adakveo Inj crizanlizumab-tmca 5mg tmca, 5 mg Injection, corticorelin ovine J0795 No Auth. Required Acthrel Corticorelin ovine triflutal triflutate, 1 microgram Injection, corticotropin, up to 40 J0800 Auth Required HP-Acthar Corticotropin injection units J0834 No Auth. Required Cosyntropin Injection, cosyntropin, 0.25 mg Inj., cosyntropin, 0.25 mg Injection, crotalidae polyvalent J0840 No Auth. Required CroFab Crotalidae poly immune fab immune fab (ovine), up to 1 gram Injection, crotalidae immune f(ab')2 J0841 No Auth. Required Anavip Inj crotalidae im f(ab')2 eq (equine), 120 mg Injection, cytomegalovirus immune J0850 Auth Required Cytogam globulin intravenous (human), per Cytomegalovirus imm iv /vial vial

Effective 7/1/2021 J0875 Auth Required Dalvance Injection, dalbavancin, 5 mg Injection, dalbavancin J0878 No Auth. Required Cubicin Injection, daptomycin, 1 mg Daptomycin injection Injection, darbepoetin alfa, 1 J0881 Auth Required Aranesp Darbepoetin alfa, non-esrd microgram (non-esrd use) Injection, darbepoetin alfa, 1 J0882 No Auth. Required Aranesp Darbepoetin alfa, esrd use microgram (for esrd on dialysis) Injection, argatroban, 1 mg (for non- J0883 No Auth. Required Argatroban Argatroban nonesrd use 1mg esrd use) Injection, argatroban, 1 mg (for J0884 No Auth. Required Argatroban Argatroban esrd dialysis 1mg esrd on dialysis) Injection, epoetin alfa, (for non-esrd J0885 Auth Required Epogen Procrit Epoetin alfa, non-esrd use), 1000 units Injection, epoetin alfa, 1000 units J0886 No Auth. Required Epogen Procrit Epoetin alfa 1000 units esrd (for esrd on dialysis) Injection, epoetin beta, 1 J0887 Auth Required Mircera Epoetin beta esrd use microgram, (for esrd on dialysis) Injection, epoetin beta, 1 J0888 Auth Required Mircera Epoetin beta non esrd microgram, (for non esrd use) Injection, peginesatide, 0.1 mg (for J0890 Auth Required Peginesatide injection esrd on dialysis) J0894 Auth Required Dacogen Injection, decitabine, 1 mg Decitabine injection Injection, deferoxamine mesylate, J0895 Auth Required Desferal Deferoxamine mesylate inj 500 mg Injection, luspatercept-aamt, J0896 Auth Required Reblozyl Inj luspatercept-aamt 0.25mg 0.25 mg J0897 Auth Required Prolia Xgeva Injection, denosumab, 1 mg Denosumab injection Injection, depo-estradiol cypionate, J1000 No Auth. Required Depo-Estradiol Depo-estradiol cypionate inj up to 5 mg Injection, methylprednisolone Methylprednisolone 20 mg J1020 No Auth. Required Depo-Medrol acetate, 20 mg inj Injection, methylprednisolone Methylprednisolone 40 mg J1030 No Auth. Required Depo-Medrol acetate, 40 mg inj Injection, methylprednisolone Methylprednisolone 80 mg J1040 No Auth. Required Depo-Medrol acetate, 80 mg inj Injection, medroxyprogesterone Medroxyprogesterone J1050 No Auth. Required Depo-Provera acetate, 1 mg acetate Injection, testosterone cypionate, 1 J1071 No Auth. Required Depo-Testosterone Inj testosterone cypionate mg Injection, dexamethasone 9 J1095 Auth Required Dexycu Injection, dexamethasone 9% percent, intraocular, 1 microgram Dexamethasone, lacrimal Dexametha opth insert 0.1 J1096 Auth Required Dextenza ophthalmic insert, 0.1 mg mg Phenylephrine 10.16 mg/ml and J1097 No Auth. Required Omidria ketorolac 2.88 mg/ml ophthalmic Phenylep ketorolac opth soln irrigation solution, 1 ml Injection, dexamethasone sodium J1100 No Auth. Required Decadron Dexamethasone sodium phos phosphate, 1 mg Injection, dihydroergotamine J1110 No Auth. Required D.H.E. Inj dihydroergotamine mesylt mesylate, per 1 mg Injection, acetazolamide sodium, up J1120 No Auth. Required Acetazolamide Acetazolamid sodium injectio to 500 mg J1160 No Auth. Required Lanoxin Injection, digoxin, up to 0.5 mg Digoxin injection Injection, digoxin immune fab J1162 No Auth. Required Digifab Digoxin immune fab (ovine) (ovine), per vial Injection, phenytoin sodium, per 50 J1165 No Auth. Required Dilantin Phenytoin sodium injection mg Injection, hydromorphone, up to 4 J1170 No Auth. Required Dilaudid Hydromorphone injection mg Injection, dexrazoxane J1190 No Auth. Required Zinecard Dexrazoxane hcl injection hydrochloride, per 250 mg Injection, diphenhydramine hcl, up J1200 No Auth. Required Benadryl Diphenhydramine hcl injectio to 50 mg Injection, cetirizine J1201 Auth Required Quzyttir Inj. cetirizine hcl 0.5mg hydrochloride, 0.5 mg Injection, chlorothiazide sodium, J1205 No Auth. Required Diuril Chlorothiazide sodium inj per 500 mg Injection, dmso, dimethyl sulfoxide, J1212 No Auth. Required Rimso-50 Dimethyl sulfoxide 50% 50 ml 50%, 50 ml

Effective 7/1/2021 Injection, methadone hcl, up to 10 J1230 No Auth. Required Methadone Methadone injection mg Injection, dimenhydrinate, up to 50 J1240 No Auth. Required Dimenhydrinate Dimenhydrinate injection mg J1245 No Auth. Required Persantine Injection, dipyridamole, per 10 mg Dipyridamole injection Injection, dobutamine J1250 No Auth. Required Dobutamine Inj dobutamine hcl/250 mg hydrochloride, per 250 mg J1265 No Auth. Required Dopamine Injection, dopamine hcl, 40 mg Dopamine injection J1270 No Auth. Required Hecterol Injection, doxercalciferol, 1 mcg Injection, doxercalciferol 6 mL per fill J1290 Auth Required Kalbitor Injection, ecallantide, 1 mg Ecallantide injection (18 mL per 30 days) J1300 Auth Required Soliris Injection, eculizumab, 10 mg Eculizumab injection J1301 Auth Required Radicava Injection, edaravone, 1 mg Injection, edaravone, 1 mg J1303 Auth Required Ultomiris Injection, ravulizumab-cwvz, 10 mg Inj., ravulizumab-cwvz 10 mg J1322 Auth Required Vimizim Injection, elosulfase alfa, 1 mg Elosulfase alfa, injection J1324 Auth Required Fuzeon Injection, enfuvirtide, 1 mg Enfuvirtide injection J1325 Auth Required Flolan Veletri Injection, epoprostenol, 0.5 mg Epoprostenol injection J1327 No Auth. Required Integrilin Injection, eptifibatide, 5 mg Eptifibatide injection Injection, ertapenem sodium, 500 J1335 No Auth. Required Invanz Ertapenem injection mg Injection, erythromycin J1364 No Auth. Required Erythrocin Lactobionate Erythro lactobionate /500 mg lactobionate, per 500 mg Injection, estradiol valerate, up to J1380 No Auth. Required Delestrogen Estradiol valerate 10 mg inj 10 mg Injection, estrogen conjugated, per J1410 No Auth. Required Premarin Inj estrogen conjugate 25 mg 25 mg J1427 Auth Required Viltepso Injection, viltolarsen, 10 mg Inj. viltolarsen J1428 Auth Required Exondys Injection, eteplirsen, 10 mg Inj, eteplirsen, 10 mg J1429 Auth Required Vyondys 53 Inj golodirsen 10 mg Injection, golodirsen, 10 mg Injection, ethanolamine oleate, 100 J1430 No Auth. Required Ethamolin Ethanolamine oleate 100 mg mg Injection, ferric J1437 Auth Required Monoferric Inj. fe derisomaltose 10 mg derisomaltose, 10 mg Injection, ferric J1437 Auth Required Monoferric Inj. fe derisomaltose 10 mg derisomaltose, 10 mg

Injection, etanercept, 25 mg (code may be used for medicare when 8 untis per 28 J1438 Pharmacy Benefit Enbrel drug administered under the direct Etanercept injection days supervision of a physician, not for use when drug is self administered)

Injection, ferric carboxymaltose, 1 J1439 No Auth. Required Injectafer Inj ferric carboxymaltos 1mg mg Injection, filgrastim (g-csf), excludes J1442 Auth Required Neupogen Inj filgrastim excl biosimil biosimilars, 1 microgram Injection, ferric pyrophosphate J1443 No Auth. Required Triferic Inj ferric pyrophosphate cit citrate solution, 0.1 mg of iron Injection, ferric pyrophosphate J1444 Auth Required Triferic Fe pyro cit pow 0.1 mg iron citrate powder, 0.1 mg of iron Injection, tbo-filgrastim, 5 J1446 Auth Required Granix Inj, tbo-filgrastim, 5 mcg micrograms Injection, tbo-filgrastim, 1 J1447 Auth Required Granix Inj tbo filgrastim 1 microg microgram J1450 No Auth. Required Diflucan Injection fluconazole, 200 mg Fluconazole J1451 No Auth. Required Antizole Injection, fomepizole, 15 mg Fomepizole, 15 mg J1453 No Auth. Required Emend Injection, fosaprepitant, 1 mg Fosaprepitant injection Injection, fosnetupitant 235 mg and J1454 Auth Required Akynzeo Inj fosnetupitant, palonoset palonosetron 0.25 mg Injection, foscarnet sodium, per J1455 No Auth. Required Foscavir Foscarnet sodium injection 1000 mg J1458 Auth Required Naglazyme Injection, galsulfase, 1 mg Galsulfase injection Injection, immune globulin J1459 Auth Required Privigen (privigen), intravenous, non- Inj ivig privigen 500 mg lyophilized (e.g., liquid), 500 mg Injection, gamma globulin, J1460 Auth Required Gamastan Gamma globulin 1 cc inj intramuscular, 1 cc

Effective 7/1/2021 Injection, immune globulin J1554 Auth Required Asceniv Inj. asceniv (asceniv), 500 mg Injection, immune globulin J1555 Auth Required Cuvitru Inj cuvitru, 100 mg (cuvitru), 100 mg Injection, immune globulin J1556 Auth Required Bivigam Inj, imm glob bivigam, 500mg (bivigam), 500 mg Injection, immune globulin, J1557 Auth Required Gammaplex (gammaplex), intravenous, non- Gammaplex injection lyophilized (e.g., liquid), 500 mg Injection, immune globulin J1558 Auth Required Xymbify Inj. xembify, 100 mg (xembify), 100 mg Injection, immune globulin J1559 Auth Required Hizentra Hizentra injection (hizentra), 100 mg Injection, gamma globulin, J1560 Auth Required Gamastan Gamma globulin > 10 cc inj intramuscular, over 10 cc Injection, immune globulin, Gamunex-C J1561 Auth Required (gamunex-c/gammaked), non- Gamunex-c/gammaked Gammaked lyophilized (e.g., liquid), 500 mg Injection, immune globulin J1562 Auth Required Vivaglobin, inj (vivaglobin), 100 mg Injection, immune globulin, Carimune NF intravenous, lyophilized (e.g., J1566 Auth Required Panglobulin NF Immune globulin, powder powder), not otherwise specified, Gammagard S/D 500 mg Injection, immune globulin, J1568 Auth Required Octagam (octagam), intravenous, non- Octagam injection lyophilized (e.g., liquid), 500 mg Injection, immune globulin, J1569 Auth Required Gammagard (gammagard liquid), non- Gammagard liquid injection lyophilized, (e.g., liquid), 500 mg Injection, ganciclovir sodium, 500 J1570 No Auth. Required Cytovene Ganciclovir sodium injection mg Injection, hepatitis b immune J1571 Auth Required Hepagam B globulin (hepagam b), Hepagam b im injection intramuscular, 0.5 ml Injection, immune globulin, (flebogamma/flebogamma dif), J1572 Auth Required Flebogamma Flebogamma injection intravenous, non-lyophilized (e.g., liquid), 500 mg Injection, hepatitis b immune J1573 Auth Required Hepagam B globulin (hepagam b), intravenous, Hepagam b intravenous, inj 0.5 ml Injection, immune Hyqvia 100mg J1575 Auth Required Hyqvia globulin/hyaluronidase, (hyqvia), immuneglobulin 100 mg immuneglobulin Injection, garamycin, gentamicin, J1580 No Auth. Required Garamycin Garamycin gentamicin inj up to 80 mg

J1595 Pharmacy Benefit Glatopa Injection, glatiramer acetate, 20 mg Injection glatiramer acetate Injection, immune globulin, intravenous, non-lyophilized (e.g., J1599 Auth Required Panzyga Ivig non-lyophilized, nos liquid), not otherwise specified, 500 mg Injection, golimumab, 1 mg, for 120 units every 56 J1602 Auth Required Simponi Aria Golimumab for iv use 1mg intravenous use days Injection, glucagon hydrochloride, Glucagon hydrochloride/1 J1610 No Auth. Required Glucagen Hypokit per 1 mg mg Injection, granisetron J1626 No Auth. Required Kytril Granisetron hcl injection hydrochloride, 100 mcg Injection, granisetron, extended- J1627 Auth Required Sustol Inj, granisetron, xr, 0.1 mg release, 0.1 mg J1628 Pharmacy Benefit Tremfya Injection, guselkumab, 1 mg Inj., guselkumab, 1 mg J1630 No Auth. Required Haldol Decanoate Injection, haloperidol, up to 5 mg Haloperidol injection Injection, haloperidol decanoate, J1631 No Auth. Required Haldol Decanoate Haloperidol decanoate inj per 50 mg

J1632 Auth Required Zulresso Inj., brexanolone, 1 mg Injection, brexanolone, 1 mg J1640 No Auth. Required Panhematin Injection, hemin, 1 mg Hemin, 1 mg

Effective 7/1/2021 Injection, heparin sodium, (heparin J1642 No Auth. Required Heparin Lock Flush Inj heparin sodium per 10 u lock flush), per 10 units Injection, heparin sodium, per 1000 J1644 No Auth. Required Heparin Inj heparin sodium per 1000u units Injection, dalteparin sodium, per J1645 No Auth. Required Fragmin Dalteparin sodium 2500 iu Injection, enoxaparin sodium, 10 J1650 No Auth. Required Lovonox Inj enoxaparin sodium mg Injection, fondaparinux sodium, 0.5 J1652 No Auth. Required Arixtra Fondaparinux sodium mg Injection, tetanus immune globulin, J1670 No Auth. Required Hypertet Tetanus immune globulin inj human, up to 250 units Injection, hydrocortisone sodium J1720 No Auth. Required Solu-Cortef Hydrocortisone sodium succ i succinate, up to 100 mg Injection, hydroxyprogesterone J1726 Auth Required Makena Makena, 10 mg caproate, (makena), 10 mg Injection, hydroxyprogesterone Hydroxyprogesterone J1729 No Auth. Required caproate, not otherwise specified, Inj hydroxyprogst capoat nos Caproate 10 mg J1738 Auth Required Anjeso Inj. meloxicam 1 mg Injection, meloxicam, 1 mg Injection, ibandronate sodium, 1 J1740 Auth Required Boniva Ibandronate sodium injection mg J1741 No Auth. Required Caldolor Injection, ibuprofen, 100 mg Ibuprofen injection J1742 No Auth. Required Corvert Injection, ibutilide fumarate, 1 mg Ibutilide fumarate injection J1743 Auth Required Elaprase Injection, idursulfase, 1 mg Idursulfase injection J1744 Auth Required Firazyr Injection, icatibant, 1 mg Icatibant injection 18mL per 30 days Injection, infliximab, excludes 5mg/kg every 8 J1745 Auth Required Remicade Infliximab not biosimil 10mg biosimilar, 10 mg weeks J1746 Auth Required Trogarzo Injection, ibalizumab-uiyk, 10 mg Inj., ibalizumab-uiyk, 10 mg J1750 No Auth. Required Infed Injection, iron dextran, 50 mg Inj iron dextran J1756 No Auth. Required Venofer Injection, iron sucrose, 1 mg Iron sucrose injection J1786 Auth Required Cerezyme Injection, imiglucerase, 10 units Imuglucerase injection J1790 No Auth. Required Inapsine Injection, droperidol, up to 5 mg Droperidol injection Injection, propranolol hcl, up to 1 J1800 No Auth. Required Inderal Propranolol injection mg J1815 Pharmacy Benefit Insulin Injection, insulin, per 5 units Insulin injection Insulin for administration through J1817 Pharmacy Benefit Insulin Insulin for insulin pump use dme (i.e., insulin pump) per 50 units J1823 Auth Required Uplizna Injection, inebilizumab-cdon, 1 mg Inj. inebilizumab-cdon, 1 mg Injection, interferon beta-1a, 30 J1826 Pharmacy Benefit Avonex Interferon beta-1a inj mcg Injection, interferon beta-1b, 0.25 mg (code may be used for medicare when drug administered under the J1830 Auth Required Betaseron Interferon beta-1b / .25 mg direct supervision of a physician, not for use when drug is self administered) J1833 Pharmacy Benefit Cresemba Injection, isavuconazonium, 1 mg Injection, isavuconazonium Injection, ketorolac tromethamine, J1885 No Auth. Required Torodal Ketorolac tromethamine inj per 15 mg J1930 Auth Required Somatuline Depot Injection, lanreotide, 1 mg Lanreotide injection J1931 Auth Required Aldurazyme Injection, laronidase, 0.1 mg Laronidase injection J1940 Auth Required Lasix Injection, furosemide, up to 20 mg Furosemide injection Injection, aripiprazole lauroxil, J1943 No Auth. Required Aristada Inj., aristada initio, 1 mg (aristada initio), 1 mg Injection, aripiprazole lauroxil, J1944 No Auth. Required Aristada Aripirazole lauroxil 1 mg (aristada), 1 mg

Endometriosis: -every 84 days -only 1 reauth Injection, leuprolide acetate (for permitted J1950 Auth Required Lupron Depot Leuprolide acetate / 3.75 mg depot suspension), per 3.75 mg Uterine Fibroids/Leiomyo ma: every 84 days

Effective 7/1/2021 Endometriosis: -every 84 days -only 1 reauth Injection, leuprolide acetate (for permitted J1950 Auth Required Auth Required Leuprolide acetate / 7.5 mg depot suspension), per 7.5 mg Uterine Fibroids/Leiomyo ma: every 84 days

J1953 No Auth. Required Keppra Injection, levetiracetam, 10 mg Levetiracetam injection J1955 No Auth. Required Carnitor Injection, levocarnitine, per 1 gm Inj levocarnitine per 1 gm J1956 No Auth. Required Levaquin Injection, levofloxacin, 250 mg Levofloxacin injection Injection, hyoscyamine sulfate, up J1980 No Auth. Required Levsin Hyoscyamine sulfate inj to 0.25 mg Injection, lidocaine hcl for J2001 No Auth. Required Lidocaine Lidocaine injection intravenous infusion, 10 mg Injection, lincomycin hcl, up to 300 J2010 Auth Required Lincocin Lincomycin injection mg J2020 No Auth. Required Zyvox Injection, linezolid, 200 mg Linezolid injection J2060 No Auth. Required Ativan Injection, lorazepam, 2 mg Lorazepam injection J2062 Auth Required Adasuve Loxapine for inhalation, 1 mg Loxapine for inhalation 1 mg J2150 No Auth. Required Mannitol Injection, mannitol, 25% in 50 ml Mannitol injection J2170 Auth Required Increlex Injection, mecasermin, 1 mg Mecasermin injection Injection, meperidine Meperidine hydrochl /100 J2175 No Auth. Required Demerol hydrochloride, per 100 mg mg

J2182 Auth Required Nucala Injection, mepolizumab, 1 mg Injection, mepolizumab, 1mg J2185 No Auth. Required Merrem Injection, meropenem, 100 mg Meropenem Injection, meropenem and Inj., meropenem, J2186 No Auth. Required Vabomere vaborbactam, 10mg/10mg (20mg) vaborbactam Injection, methylergonovine J2210 No Auth. Required Methergine Methylergonovin maleate inj maleate, up to 0.2 mg

J2212 Auth Required Relistor Injection, methylnaltrexone, 0.1 mg Methylnaltrexone injection

J2248 No Auth. Required Mycamine Injection, micafungin sodium, 1 mg Micafungin sodium injection Injection, midazolam hydrochloride, J2250 No Auth. Required Versed Inj midazolam hydrochloride per 1 mg J2260 No Auth. Required Primacor Injection, milrinone lactate, 5 mg Inj milrinone lactate / 5 mg Injection, minocycline J2265 No Auth. Required Minocin Minocycline hydrochloride hydrochloride, 1 mg Injection, morphine sulfate, up to J2270 No Auth. Required Morphin Morphine sulfate injection 10 mg Injection, morphine sulfate, J2274 No Auth. Required Duramorph preservative-free for epidural or Inj morphine pf epid ithc intrathecal use, 10 mg J2278 Auth Required Prialt Injection, ziconotide, 1 microgram Ziconotide injection J2280 No Auth. Required Avelox Injection, moxifloxacin, 100 mg Inj, moxifloxacin 100 mg Injection, nalbuphine J2300 No Auth. Required Nubain Inj nalbuphine hydrochloride hydrochloride, per 10 mg Injection, naloxone hydrochloride, J2310 No Auth. Required Narcan Inj naloxone hydrochloride per 1 mg Injection, naltrexone, depot form, 1 J2315 No Auth. Required Vivitrol Naltrexone, depot form mg 300mg per 28 J2323 Auth Required Tysabri Injection, natalizumab, 1 mg Natalizumab injection days 12mg (5mL) per J2326 Auth Required Spinraza Injection, nusinersen, 0.1 mg Inj, nusinersen, 0.1mg treatment 600MG every 6 J2350 Auth Required Ocrevus Injection, ocrelizumab, 1 mg Injection, ocrelizumab, 1 mg months Injection, octreotide, depot form J2353 Auth Required Sandostatin LAR Octreotide injection, depot for intramuscular injection, 1 mg Injection, octreotide, non-depot J2354 Auth Required Sandostatin form for subcutaneous or Octreotide inj, non-depot intravenous injection, 25 mcg J2355 Auth Required Injection, oprelvekin, 5 mg Oprelvekin injection J2357 Auth Required Xolair Injection, omalizumab, 5 mg Omalizumab injection

Effective 7/1/2021 Injection, olanzapine, long-acting, 1 J2358 No Auth. Required Zyprexa Relprevv Olanzapine long-acting inj mg Injection, orphenadrine citrate, up J2360 No Auth. Required Norflex Orphenadrine injection to 60 mg Injection, phenylephrine hcl, up to 1 J2370 No Auth. Required Vazculep Phenylephrine hcl injection ml Injection, chloroprocaine J2400 No Auth. Required Nesacaine Chloroprocaine hcl injection hydrochloride, per 30 ml Injection, ondansetron J2405 No Auth. Required Zofran Ondansetron hcl injection hydrochloride, per 1 mg J2407 Auth Required Orbactiv Injection, oritavancin, 10 mg Injection, oritavancin Injection, palifermin, 50 J2425 No Auth. Required Kepivance Palifermin injection micrograms Injection, paliperidone palmitate J2426 No Auth. Required Invega Sustenna Paliperidone palmitate inj extended release, 1 mg Injection, pamidronate disodium, Pamidronate disodium /30 J2430 Auth Required per 30 mg mg Injection, papaverine hcl, up to 60 J2440 No Auth. Required Papaverine Papaverin hcl injection mg

J2469 No Auth. Required Aloxi Injection, palonosetron hcl, 25 mcg Palonosetron hcl J2501 No Auth. Required Zemplar Injection, paricalcitol, 1 mcg Paricalcitol Injection, pasireotide long acting, 1 J2502 Auth Required Signifor LAR Inj, pasireotide long acting mg Injection, pegaptanib sodium, 0.3 J2503 Auth Required Macugen Pegaptanib sodium injection mg

J2504 Auth Required Injection, pegademase bovine, 25 iu Pegademase bovine, 25 iu J2505 Auth Required Neulasta Injection, pegfilgrastim, 6 mg Injection, pegfilgrastim 6mg J2507 Auth Required Krystexxa Injection, pegloticase, 1 mg Pegloticase injection Injection, penicillin g procaine, J2510 No Auth. Required Penicillin G Procaine Penicillin g procaine inj aqueous, up to 600,000 units Injection, pentobarbital sodium, per J2515 No Auth. Required Nembutal Pentobarbital sodium inj 50 mg Injection, penicillin g potassium, up J2540 No Auth. Required Penicillin G Potassium Penicillin g potassium inj to 600,000 units Injection, piperacillin J2543 No Auth. Required Zosyn sodium/tazobactam sodium, 1 Piperacillin/tazobactam gram/0.125 grams (1.125 grams) Pentamidine isethionate, inhalation solution, fda-approved final J2545 No Auth. Required Nebupent product, non-compounded, Pentamidine non-comp unit administered through dme, unit dose form, per 300 mg J2547 Auth Required Rapivab Injection, peramivir, 1 mg Injection, peramivir Injection, promethazine hcl, up to J2550 No Auth. Required Phenergan Promethazine hcl injection 50 mg Injection, phenobarbital sodium, up J2560 No Auth. Required Phenobarbital Phenobarbital sodium inj to 120 mg J2562 Auth Required Mozobil Injection, plerixafor, 1 mg Plerixafor injection J2590 No Auth. Required Pitocin Injection, oxytocin, up to 10 units Oxytocin injection Injection, desmopressin acetate, J2597 No Auth. Required DDAVP Inj desmopressin acetate per 1 mcg

J2675 No Auth. Required Progesterone Injection, progesterone, per 50 mg Inj progesterone per 50 mg Injection, fluphenazine decanoate, Fluphenazine decanoate 25 J2680 No Auth. Required Prolixin up to 25 mg mg Injection, procainamide hcl, up to 1 J2690 No Auth. Required Procainamide Procainamide hcl injection gm Injection, oxacillin sodium, up to J2700 No Auth. Required Oxacillin Oxacillin sodium injeciton 250 mg J2704 No Auth. Required Diprivan Injection, propofol, 10 mg Inj, propofol, 10 mg Injection, neostigmine J2710 No Auth. Required Bloxiverz Neostigmine methylslfte inj methylsulfate, up to 0.5 mg Injection, protamine sulfate, per 10 J2720 No Auth. Required Protamine Inj protamine sulfate/10 mg mg Injection, protein c concentrate, J2724 Auth Required Ceprotin Protein c concentrate intravenous, human, 10 iu

Effective 7/1/2021 Injection, pralidoxime chloride, up J2730 No Auth. Required Protopam Pralidoxime chloride inj to 1 gm Injection, phentolamine mesylate, J2760 No Auth. Required Regitine Phentolaine mesylate inj up to 5 mg Injection, metoclopramide hcl, up J2765 No Auth. Required Reglan Metoclopramide hcl injection to 10 mg

Injection, quinupristin/dalfopristin, J2770 No Auth. Required Synercid Quinupristin/dalfopristin 500 mg (150/350) J2778 Auth Required Lucentis Injection, ranibizumab, 0.1 mg Ranibizumab injection Injection, ranitidine hydrochloride, J2780 No Auth. Required Zantac Ranitidine hydrochloride inj 25 mg J2783 No Auth. Required Elitek Injection, rasburicase, 0.5 mg Rasburicase J2785 No Auth. Required Lexiscan Injection, regadenoson, 0.1 mg Regadenoson injection J2786 Auth Required Cinqair Injection, reslizumab, 1 mg Injection, reslizumab, 1mg Riboflavin 5'-phosphate, ophthalmic J2787 Auth Required Photrexa Riboflavin 5'phos opth<=3ml solution, up to 3 ml Injection, rho d immune globulin, Rho d immune globulin 50 J2788 No Auth. Required HyperRho human, minidose, 50 micrograms mcg (250 i.u.) Injection, rho d immune globulin, J2790 No Auth. Required HyperRho S/D human, full dose, 300 micrograms Rho d immune globulin inj (1500 i.u.)

Injection, rho(d) immune globulin J2791 No Auth. Required Rhophylac (human), (rhophylac), intramuscular Rhophylac injection or intravenous, 100 iu Injection, rho d immune globulin, J2792 No Auth. Required WinRho intravenous, human, solvent Rho(d) immune globulin h, sd detergent, 100 iu J2793 Auth Required Arcalyst Injection, rilonacept, 1 mg Rilonacept injection Injection, risperidone (risperdal J2794 No Auth. Required Risperdal Consta Inj risperdal consta, 0.5 mg consta), 0.5 mg Injection, ropivacaine J2795 No Auth. Required Naropin Ropivacaine hcl injection hydrochloride, 1 mg Injection, romiplostim, 10 J2796 Auth Required Nplate Romiplostim injection micrograms J2797 Auth Required Injection, rolapitant, 0.5 mg Inj., rolapitant, 0.5 mg Injection, risperidone, (perseris), J2798 Auth Required Perseris Inj., perseris, 0.5 mg 0.5 mg Injection, methocarbamol, up to 10 J2800 No Auth. Required Robaxin Methocarbamol injection ml J2805 No Auth. Required Kinevac Injection, sincalide, 5 micrograms Sincalide injection J2810 No Auth. Required Theophylline Injection, theophylline, per 40 mg Inj theophylline per 40 mg Injection, sargramostim (gm-csf), 50 J2820 Auth Required Leukine Sargramostim injection mcg J2840 Auth Required Kanuma Injection, sebelipase alfa, 1 mg Inj sebelipase alfa 1 mg Injection, secretin, synthetic, J2850 No Auth. Required Chirhostim Inj secretin synthetic human human, 1 microgram J2860 Auth Required Sylvant Injection, siltuximab, 10 mg Injection, siltuximab Injection, sodium ferric gluconate J2916 No Auth. Required Ferrlecit complex in sucrose injection, 12.5 Na ferric gluconate complex mg Injection, methylprednisolone J2920 No Auth. Required Solu-Medrol Methylprednisolone injection sodium succinate, up to 40 mg Injection, methylprednisolone J2930 No Auth. Required Solu-Medrol Methylprednisolone injection sodium succinate, up to 125 mg J2941 Pharmacy Benefit rditropin, Omnitrope, Serostim Somatropin injection Injection, somatropin, 1 mg J2993 No Auth. Required Retavase Injection, reteplase, 18.1 mg Reteplase injection Injection, alteplase recombinant, 1 J2997 No Auth. Required Cathflo Alteplase recombinant mg

J3000 No Auth. Required Streptomycin Injection, streptomycin, up to 1 gm Streptomycin injection J3010 No Auth. Required Fentanyl Injection, fentanyl citrate, 0.1 mg Fentanyl citrate injection

Effective 7/1/2021 Injection, sumatriptan succinate, 6 mg (code may be used for medicare when drug administered under the J3030 No Auth. Required Imitrex Sumatriptan succinate / 6 mg direct supervision of a physician, not for use when drug is self administered) Injection, fremanezumab-vfrm, 1 mg (code may be used for medicare when drug administered under the Inj., fremanezumab-vfrm 1 J3031 Auth Required Ajovy direct supervision of a physician, mg not for use when drug is self- administered) Injection, eptinezumab-jjmr, J3032 Auth Required Vyepti Inj. eptinezumab-jjmr 1 mg 1 mg

J3060 Auth Required Elelyso Injection, taliglucerase alfa, 10 units Inj, taliglucerase alfa 10 u

J3090 Auth Required Sivextro Injection, tedizolid phosphate, 1 mg Inj tedizolid phosphate J3095 No Auth. Required Vibativ Injection, telavancin, 10 mg Telavancin injection J3101 No Auth. Required Tnkase Injection, tenecteplase, 1 mg Tenecteplase injection Injection, terbutaline sulfate, up to J3105 No Auth. Required Brethine Terbutaline sulfate inj 1 mg J3110 Auth Required Forteo Injection, teriparatide, 10 mcg Teriparatide injection J3111 Auth Required Evenity Injection, romosozumab-aqqg, 1 mg Inj. romosozumab-aqqg 1 mg Injection, testosterone enanthate, 1 J3121 No Auth. Required Testosterone Enanthate Inj testostero enanthate 1mg mg Injection, testosterone Testosterone undecanoate J3145 No Auth. Required Aveed undecanoate, 1 mg 1mg Injection, chlorpromazine hcl, up to J3230 No Auth. Required Thorazine Chlorpromazine hcl injection 50 mg Injection, thyrotropin alpha, 0.9 mg, J3240 No Auth. Required Thyrogen Thyrotropin injection provided in 1.1 mg vial Injection, teprotumumab- J3241 Auth Required Tepezza Inj. teprotumumab-trbw 10 mg trbw, 10 mg J3243 No Auth. Required Tygacil Injection, tigecycline, 1 mg Tigecycline injection J3245 Auth Required Ilumya Injection, tildrakizumab, 1 mg Inj., tildrakizumab, 1 mg J3246 No Auth. Required Aggrastat Injection, tirofiban hcl, 0.25 mg Tirofiban hcl Injection, trimethobenzamide hcl, J3250 No Auth. Required Tigan Trimethobenzamide hcl inj up to 200 mg Injection, tobramycin sulfate, up to J3260 No Auth. Required Tobramycin Tobramycin sulfate injection 80 mg 3200 units per 28 J3262 Auth Required Actemra Injection, tocilizumab, 1 mg Tocilizumab injection days J3285 Auth Required Remodulin Injection, treprostinil, 1 mg Treprostinil injection Injection, triamcinolone acetonide, J3300 No Auth. Required Triesence Triamcinolone a inj prs-free preservative free, 1 mg

Injection, triamcinolone acetonide, J3301 No Auth. Required Kenalog Triamcinolone acet inj nos not otherwise specified, 10 mg

Injection, triamcinolone acetonide, preservative-free, extended- J3304 Auth Required Zilretta Inj triamcinolone ace xr 1mg release, microsphere formulation, 1 mg Injection, triptorelin pamoate, 3.75 J3315 Auth Required Trelstar Triptorelin pamoate mg Injection, triptorelin, extended- J3316 Auth Required Triptodur Inj., triptorelin xr 3.75 mg release, 3.75 mg J3355 Auth Required Injection, urofollitropin, 75 iu Urofollitropin, 75 iu 90 units per 56 days after loading Ustekinumab, for subcutaneous dose J3357 Auth Required Stelara Ustekinumab sub cu inj, 1 mg injection, 1 mg Subcutaneous Administration Ustekinumab, for intravenous J3358 Auth Required Stelara Ustekinumab, iv inject, 1 mg IV administration injection, 1 mg J3360 No Auth. Required Valium Injection, diazepam, up to 5 mg Diazepam injection

Effective 7/1/2021 J3370 No Auth. Required Vancomycine Injection, vancomycin hcl, 500 mg Vancomycin hcl injection 300mg per J3380 Auth Required Entyvio Injection, vedolizumab, 1 mg Injection, vedolizumab infusion Injection, velaglucerase alfa, 100 J3385 Auth Required Vpriv Velaglucerase alfa units J3396 Auth Required Visudyne Injection, verteporfin, 0.1 mg Verteporfin injection Injection, vestronidase alfa-vjbk, 1 J3397 Auth Required Mepsevii Inj., vestronidase alfa-vjbk mg Injection, voretigene neparvovec- J3398 Auth Required Luxturna Inj luxturna 1 billion vec g rzyl, 1 billion vector genomes Injection, onasemnogene abeparvovec-xioi, per J3399 Auth Required Zolgensma Inj onase abepar-xioi treat treatment, up to 5x10^15 vector genomes Injection, hydroxyzine hcl, up to 25 J3410 No Auth. Required Vistaril Hydroxyzine hcl injection mg J3411 No Auth. Required Thiamine Injection, thiamine hcl, 100 mg Thiamine hcl 100 mg J3415 No Auth. Required Pyridoxine Injection, pyridoxine hcl, 100 mg Pyridoxine hcl 100 mg Injection, vitamin b-12 J3420 No Auth. Required Cyanocobalamine Vitamin b12 injection cyanocobalamin, up to 1000 mcg Injection, phytonadione (vitamin k), J3430 No Auth. Required Mephyton Vitamin k phytonadione inj per 1 mg J3465 No Auth. Required Vfend Injection, voriconazole, 10 mg Injection, voriconazole Injection, hyaluronidase, up to 150 J3470 No Auth. Required Amphadase Hyaluronidase injection units Injection, hyaluronidase, ovine, J3471 No Auth. Required Vitrase preservative free, per 1 usp unit (up Ovine, up to 999 usp units to 999 usp units) Injection, hyaluronidase, J3473 No Auth. Required Hylenex Hyaluronidase recombinant recombinant, 1 usp unit Injection, magnesium sulfate, per J3475 No Auth. Required Magnesium Sulfate Inj magnesium sulfate 500 mg Injection, potassium chloride, per 2 J3480 No Auth. Required Potassium Chloride Inj potassium chloride meq J3485 No Auth. Required Retrovir Injection, zidovudine, 10 mg Zidovudine Injection, ziprasidone mesylate, 10 J3486 No Auth. Required Geodan Ziprasidone mesylate mg J3489 No Auth. Required Reclast Zometa Injection, zoledronic acid, 1 mg Zoledronic acid 1mg Any drug costing more than $8000 J3490 No Auth. Required Unclassified code Unclassified drugs Drugs unclassified injection that is billed using J3490 will require a PA. J3490 Auth Required Exparel Exparel 1.3% Susp Exparel Drug administered through a J3535 No Auth. Required Unclassified code Metered dose inhaler drug metered dose inhaler Any drug costing more than $8000 J3590 Auth Required Unclassified code Unclassified biologics Unclassified biologics that is billed using J3590 will require a PA. Unclassified drug or biological used J3591 No Auth. Required Unclassified code Esrd on dialysi drug/bio noc for esrd on dialysis Infusion, normal saline solution , J7030 No Auth. Required Sodium Chloride 0.9% Normal saline solution infus 1000 cc Infusion, normal saline solution, J7040 No Auth. Required Sodium Chloride 0.9% Normal saline solution infus sterile (500 ml = 1 unit) Dextrose Sodium Chloride 5% dextrose/normal saline (500 ml J7042 No Auth. Required 5% dextrose/normal saline 5%-0.9% = 1 unit) Infusion, normal saline solution, J7050 No Auth. Required Sodium Chloride 0.9% Normal saline solution infus 250 cc

J7060 No Auth. Required Dextrose 5% 5% dextrose/water (500 ml = 1 unit) 5% dextrose/water J7070 No Auth. Required Dextrose 5% Infusion, d5w, 1000 cc D5w infusion J7100 No Auth. Required LMD in D5W 10% Infusion, dextran 40, 500 ml Dextran 40 infusion Ringers lactate infusion, up to 1000 J7120 No Auth. Required Lactated Ringers Ringers lactate infusion cc

Effective 7/1/2021 Dextrose in Lactated 5% dextrose in lactated ringers J7121 No Auth. Required 5% dextrose in lac ringers Ringers 5% infusion, up to 1000 cc J7131 No Auth. Required Sodium Chloride Hypertonic saline solution, 1 ml Hypertonic saline sol Injection, coagulation factor J7169 Auth Required Andexxa Inj andexxa, 10 mg xa (recombinant), inactivated- zhzo (andexxa), 10 mg Inj., emicizumab-kxwh 0.5 J7170 Auth Required Hemlibra Injection, emicizumab-kxwh, 0.5 mg mg J7175 Auth Required Coagadex Injection, factor x, (human), 1 i.u. Inj, factor x, (human), 1iu Injection, human fibrinogen J7177 Auth Required Fibryga Inj., fibryga, 1 mg concentrate (fibryga), 1 mg Injection, human fibrinogen J7178 Auth Required RiaStap concentrate, not otherwise Inj human fibrinogen con nos specified, 1 mg Injection, von willebrand factor J7179 Auth Required Vonvendi (recombinant), (vonvendi), 1 i.u. Vonvendi inj 1 iu vwf:rco vwf:rco Injection, factor xiii (antihemophilic J7180 Auth Required Corifact Factor xiii anti-hem factor factor, human), 1 i.u. Injection, factor xiii a-subunit, J7181 Auth Required Tretten Factor xiii recomb a-subunit (recombinant), per iu Injection, factor viii, (antihemophilic J7182 Auth Required Novoeight factor, recombinant), (novoeight), Factor viii recomb novoeight per iu Injection, von willebrand factor J7183 Auth Required Wilate complex (human), wilate, 1 i.u. Wilate injection vwf:rco Injection, factor viii (antihemophilic J7185 Auth Required Xyntha factor, recombinant) (xyntha), per Xyntha inj i.u. Injection, antihemophilic factor J7186 Auth Required Alphanate viii/von willebrand factor complex Antihemophilic viii/vwf comp (human), per factor viii i.u. Injection, von willebrand factor J7187 Auth Required Humate P Humate-p, inj complex (humate-p), per iu vwf:rco Injection, factor viii (antihemophilic J7188 Auth Required Obizur factor, recombinant), (obizur), per Factor viii recomb obizur i.u. Factor viia (antihemophilic factor, J7189 Auth Required Novoseven Factor viia recombinant), per 1 microgram Hemophil M Factor viii (antihemophilic factor, J7190 Auth Required Factor viii Koate Monoclate human) per i.u. Factor viii (antihemophilic factor J7191 Auth Required Factor viii (porcine) (porcine)), per i.u. Factor viii (antihemophilic factor, Advate Kogenate J7192 Auth Required recombinant) per i.u., not Factor viii recombinant nos FS Recombinate otherwise specified Factor ix (antihemophilic factor, J7193 Auth Required Alphanine SD Mononine Factor ix non-recombinant purified, non-recombinant) per i.u. J7194 Auth Required Profilnine Factor ix, complex, per i.u. Factor ix complex Injection, factor ix (antihemophilic J7195 Auth Required Ixinity Benefix factor, recombinant) per iu, not Factor ix recombinant nos otherwise specified

Injection, antithrombin J7196 Auth Required Atryn Antithrombin recombinant recombinant, 50 i.u. J7197 Auth Required Thrombate III Antithrombin iii (human), per i.u. Antithrombin iii injection J7198 Auth Required Feiba NF Anti-inhibitor, per i.u. Anti-inhibitor Hemophilia clotting factor, not J7199 Auth Required Unclassified code Hemophilia clot factor noc otherwise classified

Injection, factor ix, (antihemophilic J7200 Auth Required Rixubis Factor ix recombinan rixubis factor, recombinant), rixubis, per iu

Effective 7/1/2021 Injection, factor ix, fc fusion J7201 Auth Required Alprolix protein, (recombinant), alprolix, 1 Factor ix alprolix recomb i.u. Injection, factor ix, albumin fusion J7202 Auth Required Idelvion protein, (recombinant), idelvion, 1 Factor ix idelvion inj i.u.

Injection factor ix, (antihemophilic J7203 Auth Required Rebinyn factor, recombinant), Factor ix recomb gly rebinyn glycopegylated, (rebinyn), 1 iu

Injection, factor viii, antihemophilic factor J7204 Auth Required Esperocet Inj recombin esperoct per iu (recombinant), (esperoct), glycopegylated-exei, per iu Injection, factor viii fc fusion protein J7205 Auth Required Eloctate Factor viii fc fusion recomb (recombinant), per iu Injection, factor viii, (antihemophilic J7207 Auth Required Adynovate factor, recombinant), pegylated, 1 Factor viii pegylated recomb i.u.

Injection, factor viii, (antihemophilic J7208 Auth Required Jivi factor, recombinant), pegylated- Inj. jivi 1 iu aucl, (jivi), 1 i.u.

Injection, factor viii, (antihemophilic J7209 Auth Required Nuwiq Factor viii nuwiq recomb 1iu factor, recombinant), (nuwiq), 1 i.u.

Injection, factor viii, (antihemophilic J7210 Auth Required Afstyla Inj, afstyla, 1 i.u. factor, recombinant), (afstyla), 1 i.u. Injection, factor viii, (antihemophilic J7211 Auth Required Kovaltry factor, recombinant), (kovaltry), 1 Inj, kovaltry, 1 i.u. i.u. Factor viia (antihemophilic factor, J7212 Auth Required Sevenfact recombinant)-jncw (sevenfact), 1 Factor viia recomb sevenfact microgram Levonorgestrel-releasing J7296 No Auth. Required Kyleena intrauterine contraceptive system, Kyleena, 19.5 mg (kyleena), 19.5 mg Levonorgestrel-releasing J7297 No Auth. Required Liletta intrauterine contraceptive system Liletta, 52 mg (liletta), 52 mg Levonorgestrel-releasing J7298 No Auth. Required Mirena intrauterine contraceptive system Mirena, 52 mg (mirena), 52 mg J7300 No Auth. Required Paragard Intrauterine copper contraceptive Intraut copper contraceptive Levonorgestrel-releasing J7301 No Auth. Required Skyla intrauterine contraceptive system Skyla, 13.5 mg (skyla), 13.5 mg Contraceptive supply, hormone J7303 No Auth. Required Nuvaring Contraceptive vaginal ring containing vaginal ring, each Contraceptive supply, hormone Contraceptive hormone J7304 No Auth. Required Xulane containing patch, each patch Etonogestrel (contraceptive) J7307 No Auth. Required Nexplanon implant system, including implant Etonogestrel implant system and supplies Aminolevulinic acid hcl for topical J7308 No Auth. Required Levulan Kerastick administration, 20%, single unit Aminolevulinic acid hcl top dosage form (354 mg) Injection, fluocinolone acetonide, J7311 Auth Required Retisert intravitreal implant (retisert), 0.01 Inj., retisert, 0.01 mg mg Injection, dexamethasone, Dexamethasone intra J7312 Auth Required Ozurdex intravitreal implant, 0.1 mg implant Injection, fluocinolone acetonide, J7313 Auth Required Iluvien intravitreal implant (iluvien), 0.01 Inj., iluvien, 0.01 mg mg

Effective 7/1/2021 Injection, fluocinolone acetonide, J7314 Auth Required Yutiq Inj., yutiq, 0.01 mg intravitreal implant (yutiq), 0.01 mg J7315 No Auth. Required Mitosol Mitomycin, ophthalmic, 0.2 mg Ophthalmic mitomycin J7316 Auth Required Jetrea Injection, ocriplasmin, 0.125 mg Inj, ocriplasmin, 0.125 mg Hyaluronan or derivative, durolane, J7318 Auth Required Durolane Inj, durolane 1 mg 1 Injection for intra-articular injection, 1 mg Hyaluronan or derivitive, genvisc J7320 Auth Required GenVisc 850, for intra-articular injection, 1 Genvisc 850, inj, 1mg mg Hyaluronan or derivative, hyalgan, J7321 Auth Required Hyalgan Supartz supartz or visco-3, for intra-articular Hyalgan supartz visco-3 dose 5 injections injection, per dose Hyaluronan or derivative, hyalgan, J7321 Auth Required Hyalgan, Supartz, Visco-3 supartz or visco-3, for intra-articular Hyalgan supartz visco-3 dose injection, per dose 2 injections Hyaluronan or derivative, hymovis, J7322 Auth Required Hymovis Hymovis injection 1 mg for intra-articular injection, 1 mg

Hyaluronan or derivative, euflexxa, 3 injections J7323 Auth Required Euflexxa for intra-articular injection, per Euflexxa inj per dose dose Hyaluronan or derivative, orthovisc, 4 injections J7324 Auth Required Orthovisc for intra-articular injection, per Orthovisc inj per dose dose Synvisc: 3 Hyaluronan or derivative, synvisc or injections Synvisc Synvisc- J7325 Auth Required synvisc-one, for intra-articular Synvisc or synvisc-one Synvisc-One: 1 One injection, 1 mg injection

Hyaluronan or derivative, gel-one, J7326 Auth Required Gel-One for intra-articular injection, per Gel-one 1 injection dose Hyaluronan or derivative, monovisc, 1 injection J7327 Auth Required Monovisc for intra-articular injection, per Monovisc inj per dose dose Hyaluronan or derivative, gelsyn-3, J7328 Auth Required Gelsyn-3 Gelsyn-3 injection 0.1 mg 3 injections for intra-articular injection, 0.1 mg Hyaluronan or derivative, trivisc, for J7329 Auth Required Trivisc Inj, trivisc 1 mg intra-articular injection, 1 mg Autologous cultured chondrocytes, Cultured chondrocytes J7330 Auth Required MACI implant implnt Hyaluronan or derivative, J7331 Auth Required Synojoynt synojoynt, for intra-articular Synojoynt, inj., 1 mg injection, 1 mg Hyaluronan or derivative, triluron, J7332 Auth Required Triluron Inj., triluron, 1 mg 3 injections for intra-articular injection, 1 mg Capsaicin 8% patch, per square J7336 Auth Required Qutenza Capsaicin 8% patch centimeter Carbidopa 5 mg/levodopa 20 mg Carbidopa levodopa ent J7340 Auth Required Duopa enteral suspension, 100 ml 100ml Instillation, ciprofloxacin otic J7342 Auth Required Otiprio Ciprofloxacin otic susp 6 mg suspension, 6 mg Aminolevulinic acid hcl for topical J7345 Auth Required Ameluz Aminolevulinic acid, 10% gel administration, 10% gel, 10 mg Injection, bimatoprost, J7351 Auth Required Durysta Inj bimatoprost itc imp1mcg intracameral implant, 1 microgram

J7352 Auth Required Scenesse Afamelanotide implant, 1 mg Afamelanotide implant, 1 mg Mometasone furoate sinus implant, J7402 Auth Required Sinuva Mometasone sinus sinuva (sinuva), 10 micrograms J7500 Pharmacy Benefit Imuran Azathioprine, oral, 50 mg Azathioprine oral 50mg J7501 No Auth. Required Azathioprine Azathioprine, parenteral, 100 mg Azathioprine parenteral J7502 Pharmacy Benefit Neoral Sandimmune Cyclosporine, oral, 100 mg Cyclosporine oral 100 mg

Effective 7/1/2021 Tacrolimus, extended release, J7503 Pharmacy Benefit Envarsus Rx Tacrol envarsus ex rel oral (envarsus xr), oral, 0.25 mg Lymphocyte immune globulin, Lymphocyte immune J7504 Auth Required Atgam antithymocyte globulin, equine, globulin parenteral, 250 mg J7506 No Auth. Required Prednisone Prednisone, oral, per 5 mg Prednisone oral Tacrolimus, immediate release, Tacrolimus imme rel oral J7507 Pharmacy Benefit Prograf oral, 1 mg 1mg Tacrolimus, extended release, J7508 Pharmacy Benefit Astagraf XL Tacrol astagraf ex rel oral (astagraf xl), oral, 0.1 mg

J7509 Pharmacy Benefit Medrol Methylprednisolone oral, per 4 mg Methylprednisolone oral J7510 Pharmacy Benefit Orapred Pediapred Prednisolone oral, per 5 mg Prednisolone oral per 5 mg Lymphocyte immune globulin, J7511 No Auth. Required Thymoglobulin antithymocyte globulin, rabbit, Antithymocyte globuln rabbit parenteral, 25 mg Prednisone, immediate release or J7512 Pharmacy Benefit Prednisone Prednisone ir or dr oral 1mg delayed release, oral, 1 mg J7515 Pharmacy Benefit Neoral Sandimmune Cyclosporine, oral, 25 mg Cyclosporine oral 25 mg Cyclosporin parenteral J7516 No Auth. Required Sandimmune Cyclosporin, parenteral, 250 mg 250mg Mycophenolate mofetil, oral, 250 J7517 No Auth. Required Cellcept Mycophenolate mofetil oral mg J7518 Pharmacy Benefit Myfortic Mycophenolic acid, oral, 180 mg Mycophenolic acid J7520 Pharmacy Benefit Rapamune Sirolimus, oral, 1 mg Sirolimus, oral J7525 No Auth. Required Prograf Tacrolimus, parenteral, 5 mg Tacrolimus injection J7527 Pharmacy Benefit Zortress Everolimus, oral, 0.25 mg Oral everolimus Immunosuppressive drug, not J7599 No Auth. Required Unclassified code Immunosuppressive drug noc otherwise classified Acetylcysteine, inhalation solution, compounded product, administered J7604 No Auth. Required Compounded Acetylcysteine comp unit through dme, unit dose form, per gram Arformoterol, inhalation solution, fda approved final product, non- J7605 No Auth. Required Brovana compounded, administered Arformoterol non-comp unit through dme, unit dose form, 15 micrograms Formoterol fumarate, inhalation solution, fda approved final J7606 No Auth. Required Perforomist product, non-compounded, Formoterol fumarate, inh administered through dme, unit dose form, 20 micrograms Levalbuterol, inhalation solution, compounded product, administered J7607 No Auth. Required Compounded Levalbuterol comp con through dme, concentrated form, 0.5 mg Acetylcysteine, inhalation solution, fda-approved final product, non- Acetylcysteine non-comp J7608 No Auth. Required Acetylcysteine compounded, administered unit through dme, unit dose form, per gram Albuterol, inhalation solution, J7609 No Auth. Required Albuterol Sulfate compounded product, administered Albuterol comp unit through dme, unit dose, 1 mg

Albuterol, inhalation solution, compounded product, administered J7610 No Auth. Required Albuterol Sulfate Albuterol comp con through dme, concentrated form, 1 mg Albuterol, inhalation solution, fda- approved final product, non- J7611 No Auth. Required Ventolin Proventil compounded, administered Albuterol non-comp con through dme, concentrated form, 1 mg

Effective 7/1/2021 Levalbuterol, inhalation solution, fda-approved final product, non- J7612 No Auth. Required compounded compounded, administered Levalbuterol non-comp con through dme, concentrated form, 0.5 mg Albuterol, inhalation solution, fda- approved final product, non- J7613 No Auth. Required Ventolin Proventil Albuterol non-comp unit compounded, administered through dme, unit dose, 1 mg Levalbuterol, inhalation solution, fda-approved final product, non- J7614 No Auth. Required Levalbuterol Levalbuterol non-comp unit compounded, administered through dme, unit dose, 0.5 mg

Levalbuterol, inhalation solution, J7615 No Auth. Required Levalbuterol compounded product, administered Levalbuterol comp unit through dme, unit dose, 0.5 mg

Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, J7620 No Auth. Required Ipratropium Albuterol fda-approved final product, non- Albuterol ipratrop non-comp compounded, administered through dme Beclomethasone, inhalation solution, compounded product, J7622 No Auth. Required Beclomethasone Beclomethasone comp unit administered through dme, unit dose form, per milligram Betamethasone, inhalation solution, compounded product, J7624 No Auth. Required Compounded Betamethasone comp unit administered through dme, unit dose form, per milligram Budesonide, inhalation solution, fda- approved final product, non- J7626 No Auth. Required Pulmicort compounded, administered Budesonide non-comp unit through dme, unit dose form, up to 0.5 mg Budesonide, inhalation solution, compounded product, administered J7627 No Auth. Required Compounded Budesonide comp unit through dme, unit dose form, up to 0.5 mg Bitolterol mesylate, inhalation solution, compounded product, J7628 No Auth. Required Compounded Bitolterol mesylate comp con administered through dme, concentrated form, per milligram Bitolterol mesylate, inhalation solution, compounded product, J7629 No Auth. Required Compounded Bitolterol mesylate comp unt administered through dme, unit dose form, per milligram Cromolyn sodium, inhalation solution, fda-approved final Cromolyn sodium noncomp J7631 No Auth. Required Compounded product, non-compounded, unit administered through dme, unit dose form, per 10 milligrams Cromolyn sodium, inhalation solution, compounded product, J7632 Not Covered Compounded Cromolyn sodium comp unit administered through dme, unit dose form, per 10 milligrams Budesonide, inhalation solution, fda- approved final product, non- J7633 No Auth. Required Pulmicort compounded, administered Budesonide non-comp con through dme, concentrated form, per 0.25 milligram Budesonide, inhalation solution, compounded product, administered J7634 Not Covered Compounded Budesonide comp con through dme, concentrated form, per 0.25 milligram

Effective 7/1/2021 Atropine, inhalation solution, compounded product, administered J7635 Not Covered Compounded Atropine comp con through dme, concentrated form, per milligram Atropine, inhalation solution, compounded product, administered J7636 Not Covered Compounded Atropine comp unit through dme, unit dose form, per milligram Dexamethasone, inhalation solution, compounded product, J7637 Not Covered Compounded Dexamethasone comp con administered through dme, concentrated form, per milligram Dexamethasone, inhalation solution, compounded product, J7638 Not Covered Compounded Dexamethasone comp unit administered through dme, unit dose form, per milligram Dornase alfa, inhalation solution, fda-approved final product, non- J7639 Auth Required Pulmozyme compounded, administered Dornase alfa non-comp unit through dme, unit dose form, per milligram Formoterol, inhalation solution, compounded product, administered J7640 Not Covered Compounded Formoterol comp unit through dme, unit dose form, 12 micrograms Flunisolide, inhalation solution, compounded product, administered J7641 Not Covered Compounded Flunisolide comp unit through dme, unit dose, per milligram Glycopyrrolate, inhalation solution, compounded product, administered J7642 Not Covered Compounded Glycopyrrolate comp con through dme, concentrated form, per milligram Glycopyrrolate, inhalation solution, compounded product, administered J7643 Not Covered Compounded Glycopyrrolate comp unit through dme, unit dose form, per milligram Ipratropium bromide, inhalation solution, fda-approved final Ipratropium bromide non- J7644 No Auth. Required product, non-compounded, comp administered through dme, unit dose form, per milligram Ipratropium bromide, inhalation solution, compounded product, J7645 Not Covered Atrovent Ipratropium bromide comp administered through dme, unit dose form, per milligram Isoetharine hcl, inhalation solution, compounded product, administered J7647 Not Covered Compounded Isoetharine comp con through dme, concentrated form, per milligram Isoetharine hcl, inhalation solution, fda-approved final product, non- J7648 No Auth. Required compounded, administered Isoetharine non-comp con through dme, concentrated form, per milligram Isoetharine hcl, inhalation solution, fda-approved final product, non- J7649 No Auth. Required compounded, administered Isoetharine non-comp unit through dme, unit dose form, per milligram Isoetharine hcl, inhalation solution, compounded product, administered J7650 Not Covered Compounded Isoetharine comp unit through dme, unit dose form, per milligram Isoproterenol hcl, inhalation solution, compounded product, J7657 Not Covered Compounded Isoproterenol comp con administered through dme, concentrated form, per milligram

Effective 7/1/2021 Isoproterenol hcl, inhalation solution, fda-approved final J7658 No Auth. Required product, non-compounded, Isoproterenol non-comp con administered through dme, concentrated form, per milligram Isoproterenol hcl, inhalation solution, fda-approved final J7659 No Auth. Required product, non-compounded, Isoproterenol non-comp unit administered through dme, unit dose form, per milligram Isoproterenol hcl, inhalation solution, compounded product, J7660 Not Covered Compounded Isoproterenol comp unit administered through dme, unit dose form, per milligram Mannitol, administered through an J7665 No Auth. Required Mannitol Mannitol for inhaler inhaler, 5 mg Metaproterenol sulfate, inhalation solution, compounded product, J7667 Not Covered Compounded Metaproterenol comp con concentrated form, per 10 milligrams Metaproterenol sulfate, inhalation solution, fda-approved final product, non-compounded, Metaproterenol non-comp J7668 No Auth. Required Alupent administered through dme, con concentrated form, per 10 milligrams Metaproterenol sulfate, inhalation solution, fda-approved final Metaproterenol non-comp J7669 No Auth. Required Compounded product, non-compounded, unit administered through dme, unit dose form, per 10 milligrams Metaproterenol sulfate, inhalation solution, compounded product, J7670 Not Covered Compounded Metaproterenol comp unit administered through dme, unit dose form, per 10 milligrams

Methacholine chloride J7674 No Auth. Required Provocholine administered as inhalation solution Methacholine chloride, neb through a nebulizer, per 1 mg

Pentamidine isethionate, inhalation solution, compounded product, J7676 Not Covered Pentam Pentamidine comp unit dose administered through dme, unit dose form, per 300 mg Revefenacin inhalation solution, fda- approved final product, non- Revefenacin inh non-com J7677 Auth Required Yupelri compounded, administered 1mcg through dme, 1 microgram Terbutaline sulfate, inhalation solution, compounded product, J7680 Not Covered Compounded Terbutaline sulf comp con administered through dme, concentrated form, per milligram Terbutaline sulfate, inhalation solution, compounded product, J7681 Not Covered Compounded Terbutaline sulf comp unit administered through dme, unit dose form, per milligram Tobramycin, inhalation solution, fda- approved final product, non- J7682 Auth Required Tobi compounded, unit dose form, Tobramycin non-comp unit administered through dme, per 300 milligrams Triamcinolone, inhalation solution, compounded product, administered J7683 Not Covered Compounded Triamcinolone comp con through dme, concentrated form, per milligram

Effective 7/1/2021 Triamcinolone, inhalation solution, compounded product, administered J7684 Not Covered Compounded Triamcinolone comp unit through dme, unit dose form, per milligram Tobramycin, inhalation solution, compounded product, administered J7685 Not Covered Compounded Tobramycin comp unit through dme, unit dose form, per 300 milligrams Treprostinil, inhalation solution, fda- approved final product, non- J7686 Auth Required Tyvaso compounded, administered Treprostinil, non-comp unit through dme, unit dose form, 1.74 mg Noc drugs, inhalation solution J7699 Auth Required Unclassified code Inhalation solution for dme administered through dme Noc drugs, other than inhalation J7799 No Auth. Required Unclassified code Non-inhalation drug for dme drugs, administered through dme Compounded drug, not otherwise J7999 Not Covered Unclassified code Compounded drug, noc classified Antiemetic drug, J8498 No Auth. Required Unclassified code rectal/suppository, not otherwise Antiemetic rectal/supp nos specified Prescription drug, oral, non Oral prescrip drug non J8499 Auth Required Unclassified code chemotherapeutic, nos chemo J8501 Pharmacy Benefit Emend Aprepitant, oral, 5 mg Oral aprepitant J8510 Pharmacy Benefit Myleran Busulfan; oral, 2 mg Oral busulfan J8515 Pharmacy Benefit Dostinex Cabergoline, oral, 0.25 mg Cabergoline, oral 0.25mg J8520 Pharmacy Benefit Xeloda Capecitabine, oral, 150 mg Capecitabine, oral, 150 mg J8521 Pharmacy Benefit Xeloda Capecitabine, oral, 500 mg Capecitabine, oral, 500 mg Cyclophosphamide oral 25 J8530 Pharmacy Benefit Cytoxan Cyclophosphamide; oral, 25 mg mg J8540 Pharmacy Benefit Decadron Dexamethasone, oral, 0.25 mg Oral dexamethasone J8560 Pharmacy Benefit Vpesid Etoposide; oral, 50 mg Etoposide oral 50 mg J8565 Pharmacy Benefit Iressa Gefitinib, oral, 250 mg Gefitinib oral Antiemetic drug, oral, not J8597 Pharmacy Benefit Unclassified code Antiemetic drug oral nos otherwise specified J8600 Pharmacy Benefit Alkeran Melphalan; oral, 2 mg Melphalan oral 2 mg J8610 Pharmacy Benefit Rheumatrex Methotrexate; oral, 2.5 mg Methotrexate oral 2.5 mg J8650 Auth Required Nabilone, oral, 1 mg Nabilone oral Netupitant 300 mg and J8655 Pharmacy Benefit Akynzeo Oral netupitant, palonosetro palonosetron 0.5 mg, oral J8670 No Auth. Required Varubi Rolapitant, oral, 1 mg Varubi J8700 Pharmacy Benefit Temodar Temozolomide, oral, 5 mg Temozolomide J8705 Pharmacy Benefit Hycamtin Topotecan, oral, 0.25 mg Topotecan oral Prescription drug, oral, J8999 Pharmacy Benefit Unclassified code Oral prescription drug chemo chemotherapeutic, nos Injection, doxorubicin J9000 No Auth. Required Adriamycin Doxorubicin hcl injection hydrochloride, 10 mg Injection, aldesleukin, per single use J9015 Auth Required Proleukin Aldesleukin injection vial J9017 No Auth. Required Trisenox Injection, arsenic trioxide, 1 mg Arsenic trioxide injection Injection, asparaginase (erwinaze), J9019 No Auth. Required Erwinaze Erwinaze injection 1,000 iu J9022 Auth Required Tecentriq Injection, atezolizumab, 10 mg Inj, atezolizumab,10 mg J9023 Auth Required Bavencio Injection, avelumab, 10 mg Injection, avelumab, 10 mg J9025 Auth Required Vidaza Injection, azacitidine, 1 mg Azacitidine injection J9027 No Auth. Required Clolar Injection, clofarabine, 1 mg Clofarabine injection Bcg live intravesical instillation, 1 J9030 Auth Required Tice BCG Bcg live intravesical 1mg mg J9032 Auth Required Beleodaq Injection, belinostat, 10 mg Injection, belinostat, 10mg Injection, bendamustine hcl J9033 No Auth. Required Treanda Inj., treanda 1 mg (treanda), 1 mg Injection, bendamustine hcl J9034 Auth Required Bendeka Inj., bendeka 1 mg (bendeka), 1 mg J9035 Auth Required Avastin Injection, bevacizumab, 10 mg Bevacizumab injection Injection, bendamustine J9036 Auth Required Belrapzo hydrochloride, Inj. belrapzo/bendamustine (belrapzo/bendamustine), 1 mg

Effective 7/1/2021 Injection, belantamab mafodontin- Inj belantamab mafodont J9037 Auth Required Blenrep blmf, 0.5 mg blmf Injection, blinatumomab, 1 J9039 Auth Required Blincyto Injection, blinatumomab microgram Injection, bleomycin sulfate, 15 J9040 No Auth. Required Bleomycin Bleomycin sulfate injection units Injection, bortezomib (velcade), 0.1 J9041 No Auth. Required Velcade Inj., velcade 0.1 mg mg Injection, brentuximab vedotin, 1 J9042 Auth Required Adcetris Brentuximab vedotin inj mg J9043 No Auth. Required Jevtana Injection, cabazitaxel, 1 mg Cabazitaxel injection Injection, bortezomib, not J9044 Auth Required Bortezomib Inj, bortezomib, nos, 0.1 mg otherwise specified, 0.1 mg J9045 No Auth. Required Paraplatin Injection, carboplatin, 50 mg Carboplatin injection J9047 Auth Required Kyprolis Injection, carfilzomib, 1 mg Injection, carfilzomib, 1 mg J9050 No Auth. Required BICNU Injection, carmustine, 100 mg Carmustine injection J9055 Auth Required Erbitux Injection, cetuximab, 10 mg Cetuximab injection J9057 Auth Required Aliqopa Injection, copanlisib, 1 mg Inj., copanlisib, 1 mg Injection, cisplatin, powder or J9060 No Auth. Required Platinol Cisplatin 10 mg injection solution, 10 mg J9065 No Auth. Required Mavenclad Injection, cladribine, per 1 mg Inj cladribine per 1 mg Cyclophosphamide 100 mg J9070 No Auth. Required Cytoxan Cyclophosphamide, 100 mg inj J9100 No Auth. Required Cytosar Injection, cytarabine, 100 mg Cytarabine hcl 100 mg inj Injection, calaspargase pegol-mknl, J9118 Auth Required Asparlas Inj. calaspargase pegol-mknl 10 units J9119 No Auth. Required Libtayo Injection, cemiplimab-rwlc, 1 mg Inj., cemiplimab-rwlc, 1 mg J9120 No Auth. Required Cosmegen Injection, dactinomycin, 0.5 mg Dactinomycin injection J9130 No Auth. Required DTIC-Dome Dacarbazine, 100 mg Dacarbazine 100 mg inj Injection, daratumumab, 10 mg and Daratumumab, J9144 Auth Required Darzalex hyaluronidase-fihj hyaluronidase Injection, daratumumab 10 J9145 Auth Required Darzalex Injection, daratumumab, 10 mg mg J9150 No Auth. Required Daunorubicin Injection, daunorubicin, 10 mg Daunorubicin injection Injection, liposomal, 1 mg J9153 Auth Required Vyxeos daunorubicin and 2.27 mg Inj daunorubicin, cytarabine cytarabine J9155 Auth Required Firmagon Injection, degarelix, 1 mg Degarelix injection Injection, diethylstilbestrol J9165 No Auth. Required Not available in the US Diethylstilbestrol injection diphosphate, 250 mg J9171 No Auth. Required Taxotere Injection, docetaxel, 1 mg Docetaxel injection J9173 Auth Required Imfinzi Injection, durvalumab, 10 mg Inj., durvalumab, 10 mg J9175 No Auth. Required Elliotts B Solution Injection, elliotts' b solution, 1 ml Elliotts b solution per ml J9176 Auth Required Empliciti Injection, elotuzumab, 1 mg Injection, elotuzumab, 1mg Injection, enfortumab J9177 Auth Required Padvec Inj enfort vedo-ejfv 0.25mg vedotin-ejfv, 0.25 mg J9178 No Auth. Required Ellence Injection, epirubicin hcl, 2 mg Inj, epirubicin hcl, 2 mg J9179 No Auth. Required Halaven Injection, eribulin mesylate, 0.1 mg Eribulin mesylate injection J9181 No Auth. Required Etopophos Injection, etoposide, 10 mg Etoposide injection Injection, fludarabine phosphate, J9185 No Auth. Required Fludara Fludarabine phosphate inj 50 mg J9190 No Auth. Required Adrucil Injection, fluorouracil, 500 mg Fluorouracil injection Injection, gemcitabine J9198 Auth Required Infugem Inj. infugem, 100 mg hydrochloride, (infugem), 100 mg Injection, gemcitabine J9199 Auth Required Infugem Injection, infugem, 200 mg hydrochloride (infugem), 200 mg J9200 No Auth. Required FUDR Injection, floxuridine, 500 mg Floxuridine injection Injection, gemcitabine In gemcitabine hcl nos J9201 No Auth. Required Gemzar hydrochloride, not otherwise 200mg specified, 200 mg Goserelin acetate implant, per 3.6 J9202 Auth Required Zoladex Goserelin acetate implant mg Injection, gemtuzumab ozogamicin, Gemtuzumab ozogamicin 0.1 J9203 Auth Required Mylotarg 0.1 mg mg Injection, mogamulizumab-kpkc, 1 Inj mogamulizumab-kpkc, 1 J9204 Auth Required Poteligeo mg mg

Effective 7/1/2021 J9205 Auth Required Onivyde Injection, irinotecan liposome, 1 mg Inj irinotecan liposome 1 mg J9206 No Auth. Required Camptosar Injection, irinotecan, 20 mg Irinotecan injection J9207 No Auth. Required Ixempra Injection, ixabepilone, 1 mg Ixabepilone injection J9208 No Auth. Required Ifex Injection, ifosfamide, 1 gram Ifosfamide injection J9209 No Auth. Required Mesnex Injection, mesna, 200 mg Mesna injection J9210 Auth Required Gamifant Injection, emapalumab-lzsg, 1 mg Inj., emapalumab-lzsg, 1 mg Injection, idarubicin hydrochloride, J9211 No Auth. Required Idamycin Idarubicin hcl injection 5 mg Injection, interferon, alfa-2b, J9214 Auth Required Intron A Interferon alfa-2b inj recombinant, 1 million units Injection, interferon, alfa-n3, J9215 Auth Required Alferon N (human leukocyte derived), 250,000 Interferon alfa-n3 inj iu Injection, interferon, gamma 1-b, 3 J9216 Auth Required Actimmune Interferon gamma 1-b inj million units Leuprolide acetate (for Leuprolide acetate J9217 Auth Required Eligard subcutaneous inj kit), 7.5 mg suspension Leuprolide acetate (for Leuprolide acetate J9217 Auth Required Eligard subcutaneous inj kit), 22.5 mg suspension Leuprolide acetate (for Leuprolide acetate J9217 Auth Required Eligard subcutaneous inj kit), 30 mg suspension Leuprolide acetate (for Leuprolide acetate J9217 Auth Required Eligard subcutaneous inj kit), 45 mg suspension

Endometriosis: -every 84 days -only 1 reauth permitted Leuprolide acetate (for depot Leuprolide acetate J9217 Auth Required Lupron Depot suspension), 7.5 mg suspension Uterine Fibroids/Leiomyo ma: every 84 days

Endometriosis: -every 84 days -only 1 reauth permitted J9218 Auth Required Leuprolide Leuprolide acetate, per 1 mg Leuprolide acetate injection Uterine Fibroids/Leiomyo ma: every 84 days

J9223 Auth Required Zepzelca Injection, lurbinectedin, 0.1 mg Inj. lurbinectedin, 0.1 mg J9225 Auth Required Vantas Histrelin implant (vantas), 50 mg Vantas implant Histrelin implant (supprelin la), 50 J9226 Auth Required Supprelin LA Supprelin la implant mg Injection, isatuximab-irfc, 10 J9227 Auth Required Sarclisa Inj. isatuximab-irfc 10 mg mg J9228 Auth Required Yervoy Injection, ipilimumab, 1 mg Ipilimumab injection Injection, inotuzumab ozogamicin, Inj inotuzumab ozogam 0.1 J9229 Auth Required Besponsa 0.1 mg mg Injection, mechlorethamine J9230 No Auth. Required Mustargen hydrochloride, (nitrogen mustard), Mechlorethamine hcl inj 10 mg Injection, melphalan hydrochloride, Inj melphalan hydrochl 50 J9245 No Auth. Required Alkeran 50 mg mg Injection, melphalan J9246 Auth Required Evomela Inj., evomela, 1 mg (evomela), 1 mg J9250 No Auth. Required Methotrexate Methotrexate sodium, 5 mg Methotrexate sodium inj J9260 No Auth. Required Methotrexate Methotrexate sodium, 50 mg Methotrexate sodium inj J9261 No Auth. Required Arranon Injection, nelarabine, 50 mg Nelarabine injection Injection, omacetaxine Inj, omacetaxine mep, J9262 Auth Required Synribo mepesuccinate, 0.01 mg 0.01mg J9263 No Auth. Required Eloxatin Injection, oxaliplatin, 0.5 mg Oxaliplatin

Effective 7/1/2021 Injection, paclitaxel protein-bound J9264 No Auth. Required Abraxane Paclitaxel protein bound particles, 1 mg Dosing every 2 Injection, pegaspargase, per single weeks; J9266 Auth Required Oncaspar Pegaspargase injection dose vial 1 billing unit= up to 3750IU J9267 No Auth. Required Taxol Injection, paclitaxel, 1 mg Paclitaxel injection J9268 No Auth. Required Nipent Injection, pentostatin, 10 mg Pentostatin injection Injection, tagraxofusp-erzs, 10 J9269 Auth Required Elzonris Inj. tagraxofusp-erzs 10 mcg micrograms J9271 Auth Required Keytruda Injection, pembrolizumab, 1 mg Inj pembrolizumab J9280 No Auth. Required Mutamycin Injection, mitomycin, 5 mg Mitomycin injection Mitomycin pyelocalyceal J9281 Auth Required Jemlyto Mitomycin instillation instillation, 1 mg J9285 Auth Required Lartruvo Injection, olaratumab, 10 mg Inj, olaratumab, 10 mg Injection, mitoxantrone Mitoxantrone hydrochl / 5 J9293 Auth Required Novantrone hydrochloride, per 5 mg mg Injection, necitumumab, 1 J9295 Auth Required Portrazza Injection, necitumumab, 1 mg mg J9299 Auth Required Opdivo Injection, nivolumab, 1 mg Injection, nivolumab J9301 Auth Required Gazyva Injection, obinutuzumab, 10 mg Obinutuzumab inj J9302 Auth Required Arzerra Injection, ofatumumab, 10 mg Ofatumumab injection J9303 No Auth. Required Vectibix Injection, panitumumab, 10 mg Panitumumab injection Injection, pemetrexed J9304 Auth Required Pemfexy Inj. pemetrexed, 10 mg (pemfexy), 10 mg Injection, pemetrexed J9304 Auth Required Pemfexy Inj. pemetrexed, 10 mg (pemfexy), 10 mg J9305 No Auth. Required Alimta Injection, pemetrexed, 10 mg Pemetrexed injection J9306 Auth Required Perjeta Injection, pertuzumab, 1 mg Injection, pertuzumab, 1 mg J9307 No Auth. Required Folotyn Injection, pralatrexate, 1 mg Pralatrexate injection J9308 Auth Required Cyramza Injection, ramucirumab, 5 mg Injection, ramucirumab Injection, polatuzumab vedotin- Inj, polatuzumab vedotin J9309 Auth Required Polivy piiq, 1 mg 1mg Hycela is only covered for the Injection, rituximab 10 mg and oncology J9311 Auth Required Rituxan Hycela Inj rituximab, hyaluronidase hyaluronidase diagnoses.

J9312 Auth Required Rituxan Injection, rituximab, 10 mg Inj., rituximab, 10 mg Injection, moxetumomab J9313 Auth Required Lumoxiti Inj., lumoxiti, 0.01 mg pasudotox-tdfk, 0.01 mg J9315 Auth Required Istodax Injection, romidepsin, 1 mg Romidepsin injection Injection, pertuzumab, J9316 Auth Required Phesgo trastuzumab, and hyaluronidase- Pertuzu, trastuzu, 10 mg zzxf, per 10 mg Injection, sacituzumab govitecan- J9317 Auth Required Trodelvy Sacituzumab govitecan-hziy hziy, 2.5 mg J9320 No Auth. Required Zanosar Injection, streptozocin, 1 gram Streptozocin injection Injection, talimogene J9325 Auth Required Imlygic laherparepvec, per 1 million plaque Inj talimogene laherparepvec forming units J9328 Auth Required Temodar Injection, temozolomide, 1 mg Temozolomide injection J9330 Auth Required Torisel Injection, temsirolimus, 1 mg Temsirolimus injection J9340 No Auth. Required Tepadina Injection, thiotepa, 15 mg Thiotepa injection J9349 Auth Required Monjuvi Injection, tafasitamab-cxix, 2 mg Inj., tafasitamab-cxix J9351 No Auth. Required Hycamtin Injection, topotecan, 0.1 mg Topotecan injection J9352 Auth Required Yondelis Injection, trabectedin, 0.1 mg Injection trabectedin 0.1mg Injection, ado-trastuzumab Inj, ado-trastuzumab emt J9354 Auth Required Kadcyla emtansine, 1 mg 1mg Injection, trastuzumab, excludes J9355 Auth Required Herceptin Inj trastuzumab excl biosimi biosimilar, 10 mg Injection, trastuzumab, 10 mg and J9356 Auth Required Herceptin Hylecta Inj. herceptin hylecta, 10mg hyaluronidase-oysk Injection, valrubicin, intravesical, J9357 No Auth. Required Valstar Valrubicin injection 200 mg Injection, fam-trastuzumab J9358 Auth Required Enhertu Inj fam-trastu deru-nxki 1mg deruxtecan-nxki, 1 mg

Effective 7/1/2021 Injection, fam-trastuzumab J9358 Auth Required Enhertu Inj fam-trastu deru-nxki 1mg deruxtecan-nxki, 1 mg J9360 No Auth. Required Velban Injection, vinblastine sulfate, 1 mg Vinblastine sulfate inj J9370 No Auth. Required Vincasar PFS Vincristine sulfate, 1 mg Vincristine sulfate 1 mg inj Injection, vincristine sulfate J9371 Auth Required Marqibo Inj, vincristine sul lip 1mg liposome, 1 mg Injection, vinorelbine tartrate, 10 J9390 No Auth. Required Navelbine Vinorelbine tartrate inj mg J9395 No Auth. Required Faslodex Injection, fulvestrant, 25 mg Injection, fulvestrant J9400 Auth Required Zaltrap Injection, ziv-aflibercept, 1 mg Inj, ziv-aflibercept, 1mg J9600 No Auth. Required Photofrin Injection, porfimer sodium, 75 mg Porfimer sodium injection Not otherwise classified, J9999 Auth Required Unclassified code Chemotherapy drug antineoplastic drugs

intravenous infusion, bamlanivimab- Must be billed M0239 No Auth. Required bamlanivimab infusion xxxx, includes infusion and post bamlanivimab-xxxx infusion with Q0239 administration monitoring

intravenous infusion, casirivimab casirivimab and imdevimab Must be billed M0243 No Auth. Required and imdevimab includes infusion casirivi and imdevi infusion infusion with Q0243 and post administration monitoring

P9012 No Auth. Required Cryoprecipitate, each unit Cryoprecipitate each unit Infusion, albumin (human), 5%, 50 P9041 No Auth. Required Albumin (human),5%, 50ml ml Infusion, plasma protein fraction P9043 No Auth. Required Plasma protein fract,5%,50ml (human), 5%, 50 ml Infusion, albumin (human), 5%, 250 Albumin (human), 5%, 250 P9045 No Auth. Required ml ml Infusion, albumin (human), 25%, 20 Albumin (human), 25%, 20 P9046 No Auth. Required ml ml Infusion, albumin (human), 25%, 50 P9047 No Auth. Required Albumin (human), 25%, 50ml ml Infusion, plasma protein fraction Plasmaprotein P9048 No Auth. Required (human), 5%, 250 ml fract,5%,250ml P9050 No Auth. Required Granulocytes, pheresis, each unit Granulocytes, pheresis unit All potassium hydroxide (koh) Q0112 No Auth. Required Potassium hydroxide preps preparations Injection, ferumoxytol, for Q0138 No Auth. Required Feraheme treatment of iron deficiency Ferumoxytol, non-esrd anemia, 1 mg (non-esrd use) Injection, ferumoxytol, for Q0139 No Auth. Required Feraheme treatment of iron deficiency Ferumoxytol, esrd use anemia, 1 mg (for esrd on dialysis)

Chlorpromazine hydrochloride, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete Q0161 No Auth. Required Thorazine therapeutic substitute for an iv anti- Chlorpromazine hcl 5mg oral emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic Q0162 No Auth. Required Zofran substitute for an iv anti-emetic at Ondansetron oral the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Diphenhydramine hydrochloride, 50 mg, oral, fda approved prescription anti-emetic, for use as a complete Q0163 No Auth. Required Benadryl therapeutic substitute for an iv anti- Diphenhydramine hcl 50mg emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen

Effective 7/1/2021 Prochlorperazine maleate, 5 mg, oral, fda approved prescription anti- emetic, for use as a complete Prochlorperazine maleate Q0164 No Auth. Required Compazine therapeutic substitute for an iv anti- 5mg emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Granisetron hydrochloride, 1 mg, oral, fda approved prescription anti- emetic, for use as a complete Q0166 No Auth. Required Kytril therapeutic substitute for an iv anti- Granisetron hcl 1 mg oral emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic Q0167 Auth Required Inapsine substitute for an iv anti-emetic at Dronabinol 2.5mg oral the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Promethazine hydrochloride, 12.5 mg, oral, fda approved prescription anti-emetic, for use as a complete Promethazine hcl 12.5mg Q0169 No Auth. Required Phenergan therapeutic substitute for an iv anti- oral emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Perphenazine, 4 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic Q0175 No Auth. Required Trilafon substitute for an iv anti-emetic at Perphenazine 4mg oral the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Hydroxyzine pamoate, 25 mg, oral, fda approved prescription anti- emetic, for use as a complete Q0177 No Auth. Required Vistaril therapeutic substitute for an iv anti- Hydroxyzine pamoate 25mg emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Dolasetron mesylate, 100 mg, oral, fda approved prescription anti- emetic, for use as a complete Q0180 Auth Required Anzemet therapeutic substitute for an iv anti- Dolasetron mesylate oral emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen Unspecified oral dosage form, fda approved prescription anti-emetic, for use as a complete therapeutic Q0181 No Auth. Required substitute for a iv anti-emetic at the Unspecified oral anti-emetic time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Injection, bamlanivimab-xxxx, 700 Must be billed Q0239 No Auth. Required bamlanivimab bamlanivimab-xxxx mg with M0239 Injection, casirivimab and Must be billed Q0243 No Auth. Required casirivimab and imdevimab casirivimab and imdevimab imdevimab, 2400 mg with M0243 Pharmacy supply fee for initial Dispens fee Q0510 No Auth. Required immunosuppressive drug(s), first immunosupressive month following transplant

Effective 7/1/2021 Pharmacy supply fee for oral anti- cancer, oral anti-emetic or Sup fee Q0511 No Auth. Required immunosuppressive drug(s); for the antiem,antica,immuno first prescription in a 30-day period

Pharmacy dispensing fee for Q0513 No Auth. Required Disp fee inhal drugs/30 days inhalation drug(s); per 30 days Pharmacy dispensing fee for Q0514 Auth Required Disp fee inhal drugs/90 days inhalation drug(s); per 90 days Injection, fosphenytoin, 50 mg Q2009 No Auth. Required Cerebyx Fosphenytoin inj pe phenytoin equivalent Q2017 Auth Required Teniposide Injection, teniposide, 50 mg Teniposide, 50 mg Influenza virus vaccine, not Q2039 No Auth. Required Influenza virus vaccine, nos otherwise specified

Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car Q2041 Auth Required Yescarta positive viable t cells, including Axicabtagene ciloleucel car+ leukapheresis and dose preparation procedures, per therapeutic dose

Tisagenlecleucel, up to 600 million car-positive viable t cells, including Q2042 Auth Required Kymriah Tisagenlecleucel car-pos t leukapheresis and dose preparation procedures, per therapeutic dose

Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including Q2043 Auth Required Provenge Sipuleucel-t auto cd54+ leukapheresis and all other preparatory procedures, per infusion Injection, doxorubicin Q2050 Auth Required Doxil hydrochloride, liposomal, not Doxorubicin inj 10mg otherwise specified, 10 mg

Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 Q2053 Auth Required Tecartus car positive viable t cells, including Brexucabtagene car pos t leukapheresis and dose preparation procedures, per therapeutic dose

Injection, interferon beta-1a, 1 mcg Q3027 Auth Required Avonex Inj beta interferon im 1 mcg for intramuscular use Injection, interferon beta-1a, 1 mcg Q3028 Auth Required Rebif Inj beta interferon sq 1 mcg for subcutaneous use Iloprost, inhalation solution, fda- approved final product, non- Q4074 Auth Required Ventavis compounded, administered Iloprost non-comp unit dose through dme, unit dose form, up to 20 micrograms Injection, epoetin alfa, 100 units Q4081 No Auth. Required Epogen Procrit (for ESRD on dialysis) (for renal Epoetin alfa, 100 units esrd dialysis facilities and hospital use) Injection, filgrastim-sndz, biosimilar, Q5101 Auth Required Zarxio Injection, zarxio 1mcg (zarxio), 1 microgram Injection, infliximab-dyyb, Q5103 Auth Required Inflectra Injection, inflectra 10mg biosimilar, (inflectra), 10 mg Injection, infliximab-abda, Q5104 Auth Required Renflexis Injection, renflexis 10mg biosimilar, (renflexis), 10 mg Injection, epoetin alfa-epbx, Q5105 Auth Required Retacrit biosimilar, (retacrit) (for esrd on Inj retacrit esrd on dialysi dialysis), 100 units Injection, epoetin alfa-epbx, Q5106 Auth Required Retacrit biosimilar, (retacrit) (for non-esrd Inj retacrit non-esrd use use), 1000 units

Injection, epoetin alfa-epbx, Q5106 Auth Required Retacrit Inj retacrit non-esrd use biosimilar, (retacrit) (for non- esrd use), 1000 units

Effective 7/1/2021 Injection, bevacizumab-awwb, Q5107 Auth Required Mvasi Inj mvasi 10 mg biosimilar, (mvasi), 10 mg Injection, pegfilgrastim-jmdb, Q5108 Auth Required Fulphila Injection, fulphila 0.5mg biosimilar, (fulphila), 0.5 mg Injection, infliximab-qbtx, Q5109 Auth Required Ixifi Injection, ixifi, 10 mg biosimilar, (ixifi), 10 mg

Injection, filgrastim-aafi, biosimilar, Q5110 Auth Required Nivestym Injection, Nivestym 1mcg (nivestym), 1 microgram Injection, pegfilgrastim-cbqv, Q5111 Auth Required Udenyca Injection, udenyca 0.5 mg biosimilar, (udenyca), 0.5 mg Injection, trastuzumab-dttb, Q5112 Auth Required Ontruzant Inj ontruzant 10 mg biosimilar, (ontruzant), 10 mg Injection, trastuzumab-pkrb, Q5113 Auth Required Herzuma Inj herzuma 10 mg biosimilar, (herzuma), 10 mg Injection, trastuzumab-dkst, Q5114 Auth Required Ogivri Inj ogivri 10 mg biosimilar, (ogivri), 10 mg Injection, rituximab-abbs, Q5115 Auth Required Truxima Inj truxima 10 mg biosimilar, (truxima), 10 mg Injection, trastuzumab-anns, Q5116 Auth Required Trazimera Inj, Trazimera 10mg biosimilar, (kanjinti), 10mg Injection, trastuzumab-anns, Q5117 Auth Required Kanjinti Inj, Kanjinti, 10mg biosimilar, (trazimera), 10mg Injection, bevacizumab-bvzr, Q5118 Auth Required Zirabev Inj, Zirabev, 10mg biosimilar, (zirabev), 10mg Injection, rituximab-pvvr, Q5119 Auth Required Ruxience Inj ruxience, 10 mg biosimilar, (ruxience), 10 mg Injection, rituximab-pvvr, Q5119 Auth Required Ruxience Inj ruxience, 10 mg biosimilar, (ruxience), 10 mg Injection, pegfilgrastim- Q5120 Auth Required Ziextenzo Inj pegfilgrastim-bmez 0.5mg bmez, biosimilar, (ziextenzo), 0.5 mg Injection, pegfilgrastim- Q5120 Auth Required Ziextenzo Inj pegfilgrastim-bmez 0.5mg bmez, biosimilar, (ziextenzo), 0.5 mg Injection, infliximab-axxq, Q5121 Auth Required Avsola Inj. avsola, 10 mg biosimilar, (avsola), 10 mg Injection, pegfilgrastim-apgf, Q5122 Auth Required Nyvepria Inj, nyvepria biosimilar, (nyvepria), 0.5 mg Injection, sulfur hexafluoride lipid Q9950 No Auth. Required Lumason Inj sulf hexa lipid microsph microspheres, per ml Injection, perflutren lipid Q9957 No Auth. Required Definity Inj perflutren lip micros,ml microspheres, per ml High osmolar contrast material, 200- Hocm 200-249mg/ml Q9960 No Auth. Required Conray 249 mg/ml iodine concentration, iodine,1ml per ml High osmolar contrast material, 250- Hocm 250-299mg/ml Q9961 No Auth. Required Conray 299 mg/ml iodine concentration, iodine,1ml per ml High osmolar contrast material, 350- Hocm 350-399mg/ml Q9963 No Auth. Required Gastrografin 399 mg/ml iodine concentration, iodine,1ml per ml Low osmolar contrast material, 100- Locm 100-199mg/ml Q9965 No Auth. Required Omnipaque 199 mg/ml iodine concentration, iodine,1ml per ml Low osmolar contrast material, 200- Locm 200-299mg/ml Q9966 No Auth. Required Optiray 299 mg/ml iodine concentration, iodine,1ml per ml Low osmolar contrast material, 300- Locm 300-399mg/ml Q9967 No Auth. Required Optiray 399 mg/ml iodine concentration, iodine,1ml per ml Injection, non-radioactive, non- Methylene Blue Isosulfan contrast, visualization adjunct (e.g., Q9968 No Auth. Required Visualization adjunct Blue methylene blue, isosulfan blue), 1 mg Tc-99m from non-highly enriched Non-heu tc-99m add- Q9969 No Auth. Required uranium source, full cost recovery on/dose add-on, per study dose

Effective 7/1/2021 Butorphanol tartrate, nasal spray, S0012 No Auth. Required Stadol Nasal Butorphanol tartrate, nasal 25 mg S0013 Auth Required Spravato Esketamine, nasal spray, 1 mg Esketamine, nasal spray Injection, aminocaproic acid, 5 S0017 No Auth. Required Amicar Injection, aminocaproic acid grams Injection, bupivicaine S0020 No Auth. Required Marcaine Injection, bupivicaine hydro hydrochloride, 30 ml

S0028 No Auth. Required Pepcid Injection, famotidine, 20 mg Injection, famotidine, 20 mg S0030 No Auth. Required Flagyl Injection, metronidazole, 500 mg Injection, metronidazole S0032 No Auth. Required Nafcillin Injection, nafcillin sodium, 2 grams Injection, nafcillin sodium Injection, sulfamethoxazole and S0039 No Auth. Required Septra Injection, sulfamethoxazole trimethoprim, 10 ml

S0073 No Auth. Required Azactam Injection, aztreonam, 500 mg Injection, aztreonam, 500 mg Injection, cefotetan disodium, 500 S0074 No Auth. Required Cefotan Injection, cefotetan disodiu mg Injection, clindamycin phosphate, S0077 No Auth. Required Cleocin Injection, clindamycin phosp 300 mg Injection, fosphenytoin sodium, 750 S0078 No Auth. Required Cerebyx Injection, fosphenytoin sodi mg Injection, pentamidine isethionate, S0080 No Auth. Required Pentam Injection, pentamidine iseth 300 mg S0088 No Auth. Required Gleevec Imatinib, 100 mg Imatinib 100 mg S0090 No Auth. Required Viagra Sildenafil citrate, 25 mg Sildenafil citrate, 25 mg Granisetron hydrochloride, 1 mg S0091 No Auth. Required Kytril (for circumstances falling under the Granisetron 1mg medicare statute, use q0166) Injection, hydromorphone S0092 No Auth. Required Dilaudid hydrochloride, 250 mg (loading Hydromorphone 250 mg dose for infusion pump) Injection, morphine sulfate, 500 mg S0093 No Auth. Required Morphine Morphine 500 mg (loading dose for infusion pump) S0104 No Auth. Required Retrovir Zidovudine, oral, 100 mg Zidovudine, oral, 100 mg Bupropion hcl sustained release S0106 No Auth. Required Wellbutrin SR tablet, 150 mg, per bottle of 60 Bupropion hcl sr 60 tablets tablets S0108 No Auth. Required Purixan Mercaptopurine, oral, 50 mg Mercaptopurine 50 mg S0109 No Auth. Required Dolophine Methadone, oral, 5 mg Methadone oral 5mg S0117 No Auth. Required Retin A Tretinoin, topical, 5 grams Tretinoin topical 5 g Ondansetron, oral, 4 mg (for S0119 No Auth. Required Zofran circumstances falling under the Ondansetron 4 mg medicare statute, use hcpcs q code)

S0122 No Auth. Required Menopur Injection, menotropins, 75 iu Inj menotropins 75 iu S0126 No Auth. Required Gonal F Injection, follitropin alfa, 75 iu Inj follitropin alfa 75 iu S0128 No Auth. Required Follistim AQ Injection, follitropin beta, 75 iu Inj follitropin beta 75 iu S0132 Not Covered Ganirelix Acetate Injection, ganirelix acetate, 250 mcg Inj ganirelix acetat 250 mcg S0136 No Auth. Required Clozaril Clozapine, 25 mg Clozapine, 25 mg S0137 No Auth. Required Videx EC Didanosine (ddi), 25 mg Didanosine, 25 mg S0138 No Auth. Required Proscar Finasteride, 5 mg Finasteride, 5 mg S0139 No Auth. Required Minoxidil Minoxidil, 10 mg Minoxidil, 10 mg Injection, pegylated interferon alfa- S0145 No Auth. Required Pegasys Peg interferon alfa-2a/180 2a, 180 mcg per ml Injection, pegylated interferon alfa- S0148 No Auth. Required Peg-Intron Peg interferon alfa-2b/10 2b, 10 mcg Sterile dilutant for epoprostenol, 50 S0155 No Auth. Required Flolan Diluent Epoprostenol dilutant ml S0156 No Auth. Required Aromasin Exemestane, 25 mg Exemestane, 25 mg S0157 No Auth. Required Regranex Becaplermin gel 0.01%, 0.5 gm Becaplermin gel 1%, 0.5 gm S0160 No Auth. Required Zenzedi Dextroamphetamine sulfate, 5 mg Dextroamphetamine Injection, pantoprazole sodium, 40 S0164 No Auth. Required Protonix Injection pantroprazole mg S0166 No Auth. Required Zyprexa Injection, olanzapine, 2.5 mg Inj olanzapine 2.5mg S0169 No Auth. Required Rocaltrol Calcitrol, 0.25 microgram Calcitrol

Effective 7/1/2021 S0170 No Auth. Required Arimidex Anastrozole, oral, 1 mg Anastrozole 1 mg S0171 No Auth. Required Bumex Injection, bumetanide, 0.5 mg Bumetanide 0.5 mg S0172 No Auth. Required Leukeran Chlorambucil, oral, 2 mg Chlorambucil 2 mg Dolasetron mesylate, oral 50 mg S0174 No Auth. Required Anzemet (for circumstances falling under the Dolasetron 50 mg medicare statute, use q0180) S0175 No Auth. Required Flutamide Flutamide, oral, 125 mg Flutamide 125 mg S0176 No Auth. Required Hydrea Hydroxyurea, oral, 500 mg Hydroxyurea 500 mg S0178 No Auth. Required Gleostine Lomustine, oral, 10 mg Lomustine 10 mg S0179 No Auth. Required Megace Megestrol acetate, oral, 20 mg Megestrol 20 mg Procarbazine hydrochloride, oral, S0182 No Auth. Required Matulane Procarbazine, oral 50 mg

Prochlorperazine maleate, oral, 5 S0183 No Auth. Required Compazine mg (for circumstances falling under Prochlorperazine 5 mg the medicare statute, use q0164)

S0187 No Auth. Required Nolvadex Tamoxifen citrate, oral, 10 mg Tamoxifen 10 mg S0189 No Auth. Required Testopel Testosterone pellet, 75 mg Testosterone pellet 75 mg S0190 No Auth. Required Mifeprex Mifepristone, oral, 200 mg Mifepristone, oral, 200 mg S0191 No Auth. Required Cytotec Misoprostol, oral, 200 mcg Misoprostol, oral, 200 mcg Dialysis/stress vitamin supplement, S0194 No Auth. Required Renal Caps Vitamin suppl 100 caps oral, 100 capsules S0197 No Auth. Required Prenatal Vitamins Prenatal vitamins, 30-day supply Prenatal vitamins 30 day Disease management program, S0316 No Auth. Required Follow-up/reassessment follow-up/reassessment

Artificial pancreas device system (e.g., low glucose suspend (lgs) feature) including continuous S1034 No Auth. Required glucose monitor, blood glucose Art pancreas system device, insulin pump and computer algorithm that communicates with all of the devices

Sensor; invasive (e.g., subcutaneous), disposable, for use S1035 No Auth. Required Art pancreas inv disp sensor with artificial pancreas device system Transmitter; external, for use with S1036 No Auth. Required Art pancreas ext transmitter artificial pancreas device system Receiver (monitor); external, for use S1037 No Auth. Required with artificial pancreas device Art pancreas ext receiver system Mometasone furoate sinus implant, S1090 No Auth. Required Mometasone sinus implant 370 micrograms Adoptive immunotherapy i.e. development of specific anti-tumor S2107 No Auth. Required reactivity (e.g., tumor-infiltrating Adoptive immunotherapy lymphocyte therapy) per course of treatment Osteotomy, periacetabular, with S2115 No Auth. Required Periacetabular osteotomy internal fixation S2202 No Auth. Required Echosclerotherapy Echosclerotherapy Nasal endoscopy for post-operative debridement following functional S2342 No Auth. Required endoscopic sinus surgery, nasal Nasal endoscop po debrid and/or sinus cavity(s), unilateral or bilateral S3630 No Auth. Required Eosinophil count, blood, direct Eosinophil blood count Antisperm antibodies test S3655 No Auth. Required Antisperm antibodies test (immunobead) Gastrointestinal fat absorption S3708 No Auth. Required Gastrointestinal fat absorpt study Dose optimization by area under S3722 No Auth. Required the curve (auc) analysis, for Dose optimization auc - 5fu infusional 5-fluorouracil Procurement of donor sperm from S4026 No Auth. Required Procure donor sperm sperm bank

Effective 7/1/2021 Management of ovulation induction (interpretation of diagnostic tests S4042 No Auth. Required and studies, non-face-to-face Ovulation mgmt per cycle medical management of the patient), per cycle

Insertion of levonorgestrel- S4981 No Auth. Required Insert levonorgestrel ius releasing intrauterine system Contraceptive intrauterine device S4989 No Auth. Required (e.g., progestacert iud), including Contracept iud implants and supplies S4990 No Auth. Required Nicotine patches, legend Nicotine patch legend S4991 No Auth. Required Nicotine patches, non-legend Nicotine patch nonlegend S4993 No Auth. Required Contraceptive pills for birth control Contraceptive pills for bc S5000 No Auth. Required Prescription drug, generic Prescription drug, generic Prescription drug,brand S5001 No Auth. Required Prescription drug, brand name name 5% dextrose and 0.45% normal 5% dextrose and 0.45% S5010 No Auth. Required saline, 1000 ml saline 5% dextrose in lactated ringer's, S5011 No Auth. Required 5% dextrose in lactated ring 1000 ml 5% dextrose with potassium S5012 No Auth. Required 5% dextrose with potassium chloride, 1000 ml 5% dextrose/0.45% normal saline 5%dextrose/0.45%saline100 S5013 No Auth. Required with potassium chloride and 0ml magnesium sulfate, 1000 ml 5% dextrose/0.45% normal saline S5014 No Auth. Required with potassium chloride and D5w/0.45ns w kcl and mgs04 magnesium sulfate, 1500 ml

Home infusion therapy, catheter care / maintenance, not otherwise classified; includes administrative services, professional pharmacy S5497 Auth Required Hit cath care noc services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, catheter care / maintenance, simple (single lumen), includes administrative services, professional pharmacy S5498 Auth Required Hit simple cath care services, care coordination and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem Home infusion therapy, catheter care / maintenance, complex (more than one lumen), includes administrative services, S5501 Auth Required professional pharmacy services, Hit complex cath care care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, catheter care / maintenance, implanted access device, includes administrative services, professional pharmacy services, S5502 Auth Required care coordination and all necessary Hit interim cath care supplies and equipment, (drugs and nursing visits coded separately), per diem (use this code for interim maintenance of vascular access not currently in use)

Effective 7/1/2021 Home infusion therapy, all supplies S5517 Auth Required necessary for restoration of Hit declotting kit catheter patency or declotting Home infusion therapy, all supplies S5518 Auth Required Hit cath repair kit necessary for catheter repair

Home infusion therapy, all supplies S5521 Auth Required (including catheter) necessary for a Hit midline cath insert kit midline catheter insertion

S5550 No Auth. Required Insulin, rapid onset, 5 units Insulin rapid 5 u Insulin, most rapid onset (lispro or S5551 No Auth. Required Insulin most rapid 5 u aspart); 5 units Insulin, intermediate acting (nph or S5552 No Auth. Required Insulin intermed 5 u lente); 5 units S5553 No Auth. Required Insulin, long acting; 5 units Insulin long acting 5 u Insulin delivery device, reusable S5560 No Auth. Required Insulin reuse pen 1.5 ml pen; 1.5 ml size Insulin delivery device, reusable S5561 No Auth. Required Insulin reuse pen 3 ml pen; 3 ml size Insulin cartridge for use in insulin S5565 No Auth. Required delivery device other than pump; Insulin cartridge 150 u 150 units Insulin cartridge for use in insulin S5566 No Auth. Required delivery device other than pump; Insulin cartridge 300 u 300 units Insulin delivery device, disposable S5570 No Auth. Required Insulin dispos pen 1.5 ml pen (including insulin); 1.5 ml size Insulin delivery device, disposable S5571 No Auth. Required Insulin dispos pen 3 ml pen (including insulin); 3 ml size S8040 No Auth. Required Topographic brain mapping Topographic brain mapping

Ultrasound guidance for multifetal pregnancy reduction(s), technical component (only to be used when the physician doing the reduction S8055 No Auth. Required Us guidance fetal reduct procedure does not perform the ultrasound, guidance is included in the cpt code for multifetal pregnancy reduction - 59866)

Fluorine-18 fluorodeoxyglucose (f- 18 fdg) imaging using dual-head S8085 No Auth. Required Fluorine-18 fluorodeoxygluco coincidence detection system (non- dedicated pet scan) Electron beam computed Electron beam computed S8092 No Auth. Required tomography (also known as tomog ultrafast ct, cine ct) Peak expiratory flow rate (physician S8110 No Auth. Required Peak expiratory flow rate (p services) Infection control supplies, not S8301 No Auth. Required Infect control supplies nos otherwise specified Gradient pressure aid (gauntlet), S8428 No Auth. Required Ready gradient gauntlet ready made Padding for compression bandage, S8430 Auth Required Padding for comprssn bdg roll Insulin syringes (100 syringes, any S8490 No Auth. Required 100 insulin syringes size) Complex lymphedema therapy, Complex lymphedema S8950 No Auth. Required each 15 minutes therapy, Resuscitation bag (for use by patient on artificial respiration S8999 No Auth. Required Resuscitation bag during power failure or other catastrophic event) Home uterine monitor with or Home uterine monitor with S9001 No Auth. Required without associated nursing services or S9024 No Auth. Required Paranasal sinus ultrasound Paranasal sinus ultrasound

Effective 7/1/2021 Procuren or other growth factor S9055 No Auth. Required preparation to promote wound Procuren or other growth fac healing S9097 No Auth. Required Home visit for wound care Home visit wound care Diabetic management program, Diabetic management S9140 No Auth. Required follow-up visit to non-md provider program, Diabetic management program, Diabetic management S9141 Auth Required follow-up visit to md provider program, Insulin pump initiation, instruction S9145 Auth Required in initial use of pump (pump not Insulin pump initiation included)

Home infusion therapy, pain management infusion; administrative services, professional pharmacy services, S9325 No Auth. Required care coordination, and all necessary Hit pain mgmt per diem supplies and equipment, (drugs and nursing visits coded separately), per diem (do not use this code with s9326, s9327 or s9328)

Home infusion therapy, continuous (twenty-four hours or more) pain management infusion; administrative services, S9326 Auth Required professional pharmacy services, Hit cont pain per diem care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, intermittent (less than twenty-four hours) pain management infusion; administrative services, S9327 No Auth. Required professional pharmacy services, Hit int pain per diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, S9328 Auth Required Hit pain imp pump diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, chemotherapy infusion; administrative services, professional pharmacy services, S9329 No Auth. Required care coordination, and all necessary Hit chemo per diem supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with s9330 or s9331) Home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion; administrative services, S9330 Auth Required professional pharmacy services, Hit cont chem diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Effective 7/1/2021 Home infusion therapy, intermittent (less than twenty-four hours) chemotherapy infusion; administrative services, S9331 Auth Required professional pharmacy services, Hit intermit chemo diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home therapy, hemodialysis; administrative services, professional pharmacy services, S9335 No Auth. Required care coordination, and all necessary Ht hemodialysis diem supplies and equipment (drugs and nursing services coded separately), per diem

Home infusion therapy, continuous anticoagulant infusion therapy (e.g., heparin), administrative services, professional pharmacy services, S9336 Auth Required Hit cont anticoag diem care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, immunotherapy, administrative services, professional pharmacy S9338 No Auth. Required services, care coordination, and all Hit immunotherapy diem necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, S9339 Auth Required care coordination and all necessary Hit periton dialysis diem supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, anti- hemophilic agent infusion therapy (e.g., factor viii); administrative services, professional pharmacy S9345 Auth Required Hit anti-hemophil diem services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, alpha-1- proteinase inhibitor (e.g., prolastin); administrative services, professional pharmacy services, S9346 Auth Required Hit alpha-1-proteinas diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); administrative S9347 Auth Required Hit longterm infusion diem services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Effective 7/1/2021 Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., dobutamine); administrative services, S9348 Auth Required professional pharmacy services, Hit sympathomim diem care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, tocolytic infusion therapy; administrative services, professional pharmacy S9349 Auth Required services, care coordination, and all Hit tocolysis diem necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, S9351 Auth Required professional pharmacy services, Hit cont antiemetic diem care coordination, and all necessary supplies and equipment (drugs and visits coded separately), per diem

Home infusion therapy, continuous insulin infusion therapy; administrative services, professional pharmacy services, S9353 Auth Required Hit cont insulin diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, S9355 No Auth. Required care coordination, and all necessary Hit chelation diem supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, enzyme replacement intravenous therapy; (e.g., imiglucerase); administrative services, professional pharmacy S9357 Auth Required Hit enzyme replace diem services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e.g., infliximab); administrative services, professional pharmacy S9359 Auth Required Hit anti-tnf per diem services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy S9361 No Auth. Required services, care coordination, and all Hit diuretic infus diem necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Effective 7/1/2021 Home infusion therapy, anti- spasmotic therapy; administrative services, professional pharmacy S9363 No Auth. Required services, care coordination, and all Hit anti-spasmotic diem necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, total parenteral nutrition (tpn); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including S9364 Auth Required standard tpn formula (lipids, Hit tpn total diem specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem (do not use with home infusion codes s9365- s9368 using daily volume scales)

Home infusion therapy, total parenteral nutrition (tpn); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary S9365 Auth Required supplies and equipment including Hit tpn 1 liter diem standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem Home infusion therapy, total parenteral nutrition (tpn); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all S9366 Auth Required Hit tpn 2 liter diem necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem Home infusion therapy, total parenteral nutrition (tpn); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all S9367 Auth Required Hit tpn 3 liter diem necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem Home infusion therapy, total parenteral nutrition (tpn); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary S9368 Auth Required Hit tpn over 3l diem supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

Effective 7/1/2021 Home therapy, intermittent anti- emetic injection therapy; administrative services, professional pharmacy services, S9370 Auth Required Ht inj antiemetic diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home therapy; intermittent anticoagulant injection therapy (e.g., heparin); administrative services, professional pharmacy services, care coordination, and all S9372 Auth Required necessary supplies and equipment Ht inj anticoag diem (drugs and nursing visits coded separately), per diem (do not use this code for flushing of infusion devices with heparin to maintain patency)

Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary S9373 No Auth. Required supplies and equipment (drugs and Hit hydra total diem nursing visits coded separately), per diem (do not use with hydration therapy codes s9374-s9377 using daily volume scales)

Home infusion therapy, hydration therapy; one liter per day, administrative services, professional pharmacy services, S9374 Auth Required Hit hydra 1 liter diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, S9375 Auth Required professional pharmacy services, Hit hydra 2 liter diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day, administrative services, S9376 Auth Required professional pharmacy services, Hit hydra 3 liter diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, hydration therapy; more than three liters per day, administrative services, S9377 Auth Required professional pharmacy services, Hit hydra over 3l diem care coordination, and all necessary supplies (drugs and nursing visits coded separately), per diem

Effective 7/1/2021 Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, S9379 No Auth. Required Hit noc per diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Delivery or service to high risk areas S9381 Auth Required requiring escort or extra protection, Hit high risk/escort per visit Anticoagulation clinic, inclusive of S9401 Auth Required all services except laboratory tests, Anticoag clinic per session per session Pharmacy compounding and S9430 No Auth. Required Pharmacy comp/disp serv dispensing services Diabetic management program, Diabetic management S9455 No Auth. Required group session program, Diabetic management program, Diabetic management S9460 No Auth. Required nurse visit program, Diabetic management program, Diabetic management S9465 No Auth. Required dietitian visit program, Enterostomal therapy by a S9474 No Auth. Required registered nurse certified in Enterostomal therapy by a re enterostomal therapy, per diem Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, S9490 No Auth. Required Hit corticosteroid/diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary S9494 Auth Required Hit antibiotic total diem supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with home infusion codes for hourly dosing schedules s9497-s9504)

Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy S9497 No Auth. Required Hit antibiotic q3h diem services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy S9500 Auth Required Hit antibiotic q24h diem services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Effective 7/1/2021 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy S9501 Auth Required Hit antibiotic q12h diem services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy S9502 Auth Required Hit antibiotic q8h diem services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services, professional pharmacy services, S9503 Auth Required Hit antibiotic q6h diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, S9504 Auth Required Hit antibiotic q4h diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, g-csf, gm-csf); administrative services, S9537 Auth Required professional pharmacy services, Ht hem horm inj diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home transfusion of blood product(s); administrative services, professional pharmacy services, S9538 No Auth. Required care coordination and all necessary Hit blood products diem supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem

Home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, S9542 Auth Required Ht inj noc per diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home injectable therapy; growth hormone, including administrative services, professional pharmacy S9558 No Auth. Required services, care coordination, and all Ht inj growth horm diem necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Effective 7/1/2021 Home injectable therapy, interferon, including administrative services, professional pharmacy S9559 No Auth. Required services, care coordination, and all Hit inj interferon diem necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home injectable therapy; hormonal therapy (e.g.; leuprolide, goserelin), including administrative services, professional pharmacy services, S9560 No Auth. Required Ht inj hormone diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home injectable therapy, palivizumab, including administrative services, professional pharmacy services, S9562 No Auth. Required Ht inj palivizumab diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including administrative services, S9590 Auth Required professional pharmacy services, Ht irrigation diem care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Lodging, per diem, not otherwise S9976 No Auth. Required Lodging per diem classified Injection, buprenorphine extended- Buprenorphine xr over 100 Q9992 Auth Required Sublocade release (sublocade), greater than mg 100 mg Injection, buprenorphine extended- Q9991 Auth Required Sublocade release (sublocade), less than or Buprenorph xr 100 mg or less equal to 100 mg

IN-EXC-P-703906 Effective 7/1/2021