CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

palivizumab (respiratory syncytial virus 90378 immune globulin Medical Synagis (CPT) [RSV-IgIM], for intramuscular use, 50 (PA) mg, each)

lutetium lu 177, dotatate, therapeutic, Medical A9513 Lutathera 1 millicureie (PA)

Medical A9590 Azedra Iodine I-131, iobenguane, 1 millicurie (PA)

radium ra-223 dichloride, therapeutic, Medical A9606 Xofigo per microcurie (PA)

in-line cartridge digestive enzyme for B4105 Relizorb Medical enteral feeding each

COCAINE HCI NASAL SOL TOP ADMN 1 C9046 Goprelto Medical MG

Medical C9047 Cablivi Injection, caplacizumab-yhdp, 1 mg (PA)

Injection, romidepsin, non-lyophilized C9065 Medical (e.g. liquid), 1mg

injection, belantamab mafodontin- C9069 Blenrep Medical blmf, 0.5 mg

C9070 Monjuvi injection, tafasitamab-cxix, 2 mg Medical

Medical C9071 Viltepso Injection, viltolarsen, 10 mg (PA)

injection, immune globulin (asceniv), Medical C9072 Asceniv 500 mg (PA)

Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car Medical C9073 Tecartus positive viable t cells, including (PA) leukapheresis and dose preparation procedures, per therapeutic dose

Effective April 1, 2021 1

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

prothrombin complex concentrate C9132 Kcentra (human), kcentra, per i.u. of factor ix Medical activity

C9248 Cleviprex injection, clevidipine butyrate Medical

C9250 Artiss artiss fibrin sealant Medical

C9290 Exparel injection, bupivacaine liposome, 1 mg Medical

C9293 Voraxaze injection, glucarpidase, 10 units Medical

C9399 Unclassified Medical

C9462 Baxdela injection, delafloxacin, 1 mg Medical

C9482 Sotalol injection, sotalol hydrochloride, 1 mg Medical

injection, conivaptan hydrochloride, 1 C9488 Vaprisol Medical mg

D4381 Arestin minocycline microspheres, 1 mg Medical

Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other May bill either benefit, PA required G2082 Spravato Either (PA) qualified health care professional and regardless of benefit 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 May bill either benefit, PA required G2083 Spravato qualified health care professional and Either (PA) regardless of benefit provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post-administration observation

Medical J0121 Nuzyra Injection, omadacycline, 1 mg (PA)

Effective April 1, 2021 2

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J0122 Xerava Injection, eravacycline, 1 mg Medical

injection, abatacept, 10 mg (code may be used for medicare when drug May bill either benefit, PA required J0129 Orencia administered under the direct Either (PA) regardless of benefit supervision of a physician, not for use when drug is self-administered)

J0130 Reopro injection abciximab, 10 mg Medical

J0132 Acetadote injection, acetylcysteine, 100 mg Medical

J0133 injection, acyclovir, 5 mg Medical

Pharmacy J0135 Humira injection, adalimumab, 20 mg (PA)

J0153 Adenoscan injection, adenosine , 1 mg Medical

injection, adrenalin, epinephrine, 0.1 J0171 Medical mg

J0178 Eylea injection, aflibercept, 1 mg Medical

J0179 Beovu Injection, brolucizumab-dbll, 1 mg Either

Medical J0180 Fabrazyme injection, agalsidase beta, 1 mg (PA)

J0185 Cinvanti injection, aprepitant, 1 mg Medical

Medical J0202 Lemtrada injection alemtuzumab 1 mg (PA)

J0205 Ceredase injection, alglucerase, 1 mg Medical

J0207 Ethyol injection, amifostine, 500 mg Medical

injection, methyldopate hcl, up to 250 J0210 Medical mg

J0215 Amevive alefacept Medical

injection, alglucosidase alfa, 10 mg, not Medical J0220 Myozyme otherwise specified (PA)

Effective April 1, 2021 3

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, alglucosidase alfa, (lumizyne), Medical J0221 Lumizyme 10 mg (PA)

Medical J0222 Onpattro Injection, Patisiran, 0.1 mg (PA)

Medical J0223 Givlaari Injection, givosiran, 0.5 mg (PA)

injection, alpha 1-proteinase inhibitor Aralast NP, Prolastin, Medical J0256 (human), not otherwise specified, 10 Prolastin C, Zemaira (PA) mg

injection, alpha 1 proteinase inhibitor Medical J0257 Glassia (human), (glassia), 10 mg (PA)

J0270 Caverject, Edex prostaglandin e1,ic Pharmacy

J0275 Muse alprostadil urethral suppository Pharmacy

J0278 injection, amikacin sulfate, 100 mg Medical

J0280 injection, aminophyllin, up to 250 mg Medical

J0285 injection, amphotericin b, 50mg Medical

injection, amphotericin b lipid complex, J0287 Abelcet Medical 10 mg

injection, ampho b cholesteryl sulfate, J0288 Amphotec Medical 10mg

injection, amphotericin b liposome, J0289 Ambisome Medical 10mg

J0290 injection, ampicillin sodium, 500 mg Medical

J0291 Zemdri Injection, plazomicin, 5 mg Medical

injection, ampicillin sodium/sulbactam J0295 Medical sodium, per 1.5 g

J0348 Eraxis injection, anidulafungin, 1 mg Medical

J0360 injection, hydralazine hcl, up to 20 mg Medical

Effective April 1, 2021 4

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, apomorphine hydrochloride 1 Pharmacy J0364 Apokyn mg (PA)

J0365 Trasylol injection, aprtonin, 10,000kiu Medical

J0400 injection, aripiprazole, im 0.25mg Medical

May bill either benefit, PA required injection, aripiprazole, extended J0401 Abilify Maintena Either when billing through pharmacy release, 1 mg benefit

J0456 Zithromax injection, azithromycin, 500 mg Medical

J0461 injection, atropine sulfate, 0.01 mg Medical

J0470 Bal in Oil injection, dimecaprol 100mg Medical

J0475 Lioresal injection, baclofen, 10 mg Medical

injection, baclofen, 50 mcg for J0476 Gablofen, Lioresal Medical intrathecal trial

Medical J0485 Nulojix injection, belatacept, 1 mg (PA)

Pharmacy J0490 Benlysta injection, belimumab, 10 mg (PA)

J0500 Bentyl injection, dicyclomine hcl, up to 20 mg Medical

injection, benztropine mesylate, per 1 J0515 Cogentin Medical mg

Medical J0517 Fasenra Injection, benralizumab, 1 mg (PA)

injection, penicillin g benzathine and J0558 Bicillin C-R Medical penicillin g procaine, 100,000 units

injection, penicillin g benzathine, J0561 Bicillin L-A Medical 100,000 units

Medical J0565 Zinplava injection, bezlotoxumab, 10 mg (PA)

Medical J0567 Brineura injection, cerliponase alfa, 1 mg (PA)

Effective April 1, 2021 5

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Medical J0570 Probuphine buprenorphine implant 74.2mg (PA)

J0571 Subutex buprenorphine, oral , 1 mg Pharmacy

buprenorphine/naloxone, oral, less J0572 Suboxone Pharmacy than or equal to 3 mg

buprenorphine/naloxone, oral, greater J0573 Suboxone than 3 mg but less than or equal to 6 Pharmacy mg

buprenorphine/naloxone, oral, greater J0574 Suboxone than 6 mg , but less than or equal to 10 Pharmacy mg

buprenorphine/naloxone, oral, greater J0575 Suboxone Pharmacy than 10 mg

J0583 Angiomax injection, bivalirudin, 1 mg Medical

Medical J0584 Crysvita inj burosumab-twza, 1mg (PA)

Medical J0585 Botox injection, onabotulinumtoxina, 1 unit (PA)

Medical J0586 Dysport injection, abobotulinumtoxina (PA)

injection, rimabotulinumtoxinb, 100 Medical J0587 Myobloc units (PA)

Medical J0588 Xeomin injection, incobotulinumtoxina, 1 unit (PA)

Medical J0592 injection, buprenorphine hcl, 0.1 mg (PA)

Pharmacy J0593 Takhzyro Injection, lanadelumab-flyo, 1 mg (PA)

J0594 injection, busulfan, 1 mg Medical

J0595 injection, butorphanol tartrate, 1 mg Medical

Effective April 1, 2021 6

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, c1 esterase inhib ruconest 10 Pharmacy J0596 Ruconest u (PA)

injection, c-1 esterase inhibitor Pharmacy J0597 Berinert (human), berinert, 10 units (PA)

Pharmacy J0598 Cinryze injection, c-1 esterase, 10 units (PA)

injection, c-1 esterase inhibitor Pharmacy J0599 Haegarda (human), (haegarda), 10 units (PA)

injection, edetate calcium disodium, J0600 Medical 1000mg

cinacalcet, oral, 1mg (for esrd on J0604 Sensipar Pharmacy dialysis)

J0606 Parsabiv injection, etelcalcetide, 0.1 mg Medical

J0610 injection, calcium gluconate, per 10 ml Medical

injection, calcitonin salmon, up to 400 J0630 Micalcin Pharmacy units

J0637 Canidas injection, caspofungin acetate, 5 mg Medical

Medical J0638 Ilaris injection, canakinumab (PA)

J0640 injection, leucovorin calcium, per 50 mg Medical

Injection, levoleucovorin, not J0641 Medical otherwise specified, 0.5 mg

Injection, levoleucovorin (khapzory), J0642 Khapzory Medical 0.5 mg

J0670 Polocaine injection, mepivacaine hcl, per 10 ml Medical

J0690 injection, cefazolin sodium, 500 mg Medical

Medical J0691 Xenleta Injection, lefamulin, 1 mg (PA)

J0692 Maxipime injection, cefepime hcl, 500 mg Medical

Effective April 1, 2021 7

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J0693 Fetroja Injection, cefiderocol, 5 mg Medical

J0694 Mefoxin injection, cefoxitin sodium, 1 g Medical

injection, ceftolozane 50 mg & taz 25 J0695 Zerbaxa Medical mg

injection, ceftriaxone sodium, per 250 J0696 Rocephin Medical mg

injection, sterile cefuroxime sodium, J0697 Zinacef Medical per 750 mg

J0698 Claforan injection, cefotaxime sodium, per g Medical

injection, betamethasone acetate 3 mg J0702 Celestone Soluspan and betamethasone sodium phosphate Medical 3 mg

J0706 injection, caffeine citrate, 5 mg i Medical

J0712 Teflaro injection, ceftaroline fosamil, 10 mg Medical

J0713 Fortaz injection, ceftazidime, per 500 mg Medical

injection, ceftazidime and avibactam, J0714 Avycaz Medical 0.5 g/0.125 g

injection, centruroides immune f(ab)2, J0716 Anascorp Medical up to 120 mg

Either (PA) Syringes: This Jcode is shared by two injection, certolizumab pegol, 1 mg pharmacy different dosage forms (Cimzia vial (code may be used for medicare when benefit and syringe). Cimzia syringes are J0717 Cimzia drug administered under the direct ONLY covered with a PA on the pharmacy supervision of a physician, not for use Vials: benefit only. Cimzia vial is covered when drug is self administered) medical with a PA on the medical benefit benefit only. ONLY

injection, choloramphenicol sodium, J0720 Medical 1gm

J0725 Novarel injection, gonadotropin, 1000units Medical

Effective April 1, 2021 8

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J0735 Duraclon injection, clonidine hcl, 1 mg Medical

J0740 Vistide injection, cidofovir, 375 mg Medical

Injection, imipenem 4 mg, cilastatin 4 J0742 Recarbrio Medical mg and relebactam 2 mg

injection, cilastatin sodium; imipenem, J0743 Primaxin Medical per 250 mg

injection, ciprofloxacin for intravenous J0744 Cipro Medical infusion, 200 mg

injection, codeine phosphate, per 30 J0745 Medical mg

injection, colistimethate sodium, up to J0770 Coly-Mycin Medical 150mg

injection, collagenase, clostridium J0775 Xiaflex Medical histolyticum, 0.01 mg

injection, prochlorperazine, up to 10 J0780 Medical mg

Medical J0791 Adakveo Injection, crizanlizumab-tmca, 5 mg (PA)

injection, corticorelin ovine triflutate, 1 J0795 Acthrel Medical mcg

Pharmacy J0800 Acthar Gel injection, corticotropin, up to 40 units (PA)

injection, cosyntropin (cortrosyn), 0.25 J0834 Medical mg

injection, crotalidae polyvalent immune J0840 Crofab Medical fab (ovine), up to 1 gm

injection, crotalidae immune f(ab')2 J0841 Anavip Medical (equine), 120 mg

injection, cymomegalovirus imm, per J0850 Cytogam Medical vial

J0875 Dalvance injection dalbavancin 5mg Medical

Effective April 1, 2021 9

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J0878 Cubicin injection, daptomycin, 1 mg Medical

May bill either benefit, PA required injection, , 1 mcg (non- J0881 Aranesp Either when billing through pharmacy esrd use) benefit

May bill either benefit, PA required injection, darbepoetin alfa, 1 mcg (for J0882 Aranesp Either when billing through pharmacy esrd on dialysis) benefit

J0883 Argatroban injection, argatroban 1mg non esrd use Medical

injection, argatroban 1mg esrd on J0884 Argatroban Medical dialysis

May bill either benefit, PA required injection, epoetin alfa, (for non-esrd J0885 Procrit/Epogen Either when billing through pharmacy use), 1000 units benefit

injection, epoetin beta, 1 mcg (for esrd J0887 Mircera Medical on dialysis)

injection, epoetin beta, 1 mcg (for non- J0888 Mircera Medical esrd use)

injection, , 0.1 mg (for esrd J0890 Omontys Medical on dialysis)

J0894 Dacogen injection, decitabine, 1 mg Medical

injection, deferoxamine mesylate, 500 J0895 Desferal Medical mg

Medical J0896 Reblozyl Injection, -aamt, 0.25 mg (PA)

This Jcode is shared by two different products. May bill either J0897 Prolia/Xgeva injection, denosumab, 1mg Either (PA) benefit. PA required regardless of benefit

injection, depo-estradiol cypionate, up J1000 Either to 5 mg

injection, methylprednisolone acetate, J1020 Methylpred Either 20 mg

Effective April 1, 2021 10

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, methylprednisolone acetate, J1030 Depo-Medrol Either 40 mg

injection, methylprednisolone acetate, J1040 Depo-Medrol Either 80 mg

Pharmacy J1071 Depo-Testosterone injection, testosterone cypionate, 1 mg (PA)

J1094 injection, dexamethasone acetate, 1 mg Either

injection, dexamethasone 9 percent, J1095 Dexycu Medical intraocular, 1 microgram

Phenylephrine 10.16 mg/ml and J1097 Omidria ketorolac 2.88 mg/ml ophthalmic Medical irrigation solution, 1 ml

injection, dexamethasone sodium J1100 Medical phosphate, 1 mg

injection, dihydroergotamine mesylate, J1110 D.H.E 45 Medical per 1 mg

injection, acetazolamide sodium, up to J1120 Medical 500 mg

J1130 Dyloject injection, diclofenac sodium 0.5mg Medical

J1160 Lanoxin injection, digoxin, up to 0.5 mg Medical

injection, digoxin immune fab (ovine), J1162 Digibind, Digfab Medical per vial

J1165 injection, phenytoin sodium, per 50 mg Medical

J1170 injection, hydromorphone, up to 4 mg Medical

J1190 Zinecard, Totect injection, dexrazoxane hcl, per 250 mg Medical

injection, diphenhydramine hcl, up to J1200 Benadryl Medical 50 mg

Injection, cetirizine hydrochloride, 0.5 J1201 Quzyttir Medical mg

Effective April 1, 2021 11

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, chlorothiazide sodium, per J1205 Diuril Medical 500 mg

injection, dmso, dimethyl sulfoxide, J1212 Rimso-50 Medical 50%, 50 ml

J1230 injection, methadone hcl 10 mg Medical

J1240 injection, dimenhydrinate, up to 50 mg Medical

J1245 injection, dipyridamole, per 10 mg Medical

J1250 injection, dobutamine hcl, per 250 mg Medical

J1260 Anzemet injection, dolasetron mesylate, 10 mg Medical

J1265 injection, dopamine hcl, 40 mg Medical

J1267 Doribax injection, doripenem, 10 mg Medical

J1270 Hectrol injection, doxercalciferol, 1 mcg Medical

Pharmacy J1290 Kalbitor injection, ecallantide (PA)

Medical J1300 Soliris injection, eculizumab, 10 mg (PA)

Pharmacy J1301 Radicava injection, edaravone 1 mg (PA)

Medical J1303 Ultomiris Injection, ravulizumab-cwvz, 10 mg (PA)

Medical J1322 Vimizim injection elosulfase alfa, 1 mg (PA)

J1324 Fuzeon injection enfurvirtide Either

Pharmacy J1325 Flolan injection, epoprostenol (PA)

J1327 Integrilin injection, eptifibatide, 5 mg Medical

J1335 Invanz injection, ertapenem sodium, 500 mg Medical

injection, erythromycin lactobionate, J1364 Medical per 500 mg

Effective April 1, 2021 12

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J1380 Delestrogen injection, estradiol valerate, 10 mg Either

J1410 Premarin injection, estrogen conjugate 25 mg Either

Medical J1427 Viltepso Injection, viltolarsen, 10 mg (PA)

Medical J1428 Exondys 51 injection, eteplirsen, 10 mg (PA)

Medical J1429 Vyondys 53 Injection, golodirsen, 10 mg (PA)

J1430 injection, ethanolamine oleate, 100mg Medical

J1437 Monoferric Injection, ferric derisomaltose, 10 mg Medical

injection, etanercept, 25 mg (code may be used for medicare when drug Pharmacy J1438 Enbrel administered under the direct (PA) supervision of a physician, not for use when drug is self-administered)

J1439 Injectafer injection, ferric carboxymaltose, 1 mg Medical

May bill either benefit, PA required J1442 Neupogen injection, filgrastim (g-csf), 1 microgram Either when billing through pharmacy benefit

J1443 Ferric Citrate inj ferric prpp cit sol 0.1 mg iron Medical

Injection, ferric pyrophosphate citrate J1444 Triferic Medical powder, 0.1 mg of iron

May bill either benefit, PA required J1447 Granix injection tbo-filgrastim 1 microg Either when billing through pharmacy benefit

J1450 Diflucan injection, fluconazole, 200 mg Medical

J1451 Antizol injection, fomepizole, 15 mg Medical

J1453 Emend injection, fosaprepitant, 1 mg Medical

injection, fosnetupitant 235 mg and J1454 Akynzeo Medical palonosetron 0.25 mg

Effective April 1, 2021 13

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Medical J1458 Naglazyme injection, galsulfase (PA)

injection, immune globulin (privigen), Medical J1459 Privigen intravenous, nonlyophilized (e.g., (PA) liquid), 500 mg

Medical J1460 Gamastan injection, gamma globulin, 1cc (PA)

injection, immune globulin (asceniv), Medical J1554 Asceniv 500 mg (PA)

injection, immune globulin (cuvitru), Medical J1555 Cuvitru 100 mg (PA)

injection, immune globulin (bivigam), Medical J1556 Bivigam 500 mg (PA)

injection, immune globulin, Medical J1557 Gammaplex (gammaplex), intravenous, (PA) nonlyophilized (e.g. liquid), 500 mg

Injection, immune globulin (xembify), Medical J1558 Xembify 100 mg (PA)

Medical J1559 Hizentra injection, immune globulin (hizentra) (PA)

Medical J1560 Gamastan injection, gamma globulin, 10cc (PA)

injection, immune globulin, Gamunex, Gammunex- Medical J1561 (gamunex/gamunex-c/gammaked), C, Gammaked (PA) nonlyophilized (e.g., liquid), 500 mg

Medical J1562 Vivaglobin injection, immune globulin (vivaglobin) (PA)

injection, immune globulin, Gammagard S/D / Medical J1566 intravenous, lyophilized (e.g., powder), Carimune Nf (PA) not otherwise specified, 500 mg

Medical J1568 Octagam injection, octagam, 500mg (PA)

Effective April 1, 2021 14

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, immune globulin, Medical J1569 Gammagard Liquid (gammagard liquid), intravenous, (PA) nonlyophilized, (e.g., liquid), 500 mg

J1570 Cytovene injection, ganciclovir sodium, 500 mg Medical

J1571 injection, hepagam b im, 0.5ml Medical

injection, immune globulin, (flebogamma/flebogamma dif), Medical J1572 Flebogamma intravenous, nonlyophilized (e.g., (PA) liquid), 500 mg

injection, hepagam b intravenous, J1573 Hepagam B Medical 0.5ml

Injection, immune Medical J1575 HyQvia globulin/hyaluronidase, (hyqvia), 100 (PA) mg immuneglobulin

injection, garamycin, gentamicin, up to J1580 Medical 80 mg

J1595 Copaxone injection, glatiramer acetate, 20 mg Pharmacy

Injection, immune globulin, Medical J1599 intravenous, non-lyophilized (e.g., (PA) liquid), not otherwise specified, 500 mg

injection, gold sodium thiomaleate, J1600 Myochcrysine Medical 50mg

injection, golimumab, 1 mg , for May bill either benefit, PA required J1602 Simponi Aria Either (PA) intraveneous use regardless of benefit

J1610 injection, glucagon hcl, per 1 mg Medical

J1626 Kytril injection, granisetron hcl, 100 mcg Medical

injection, granisetron, extended- J1627 Kytril Medical release, 0.1 mg (kytril)

Pharmacy J1628 Tremfya injection, guselkumab, 1 mg (PA)

Effective April 1, 2021 15

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

May bill either benefit, PA required J1630 Haldol injection, haloperidol, up to 5 mg Either when billing through pharmacy benefit

May bill either benefit, PA required J1631 Haldol injection, haloperidol decanoate, 50 mg Either when billing through pharmacy benefit

Medical J1632 Zulresso Injection, brexanolone, 1 mg (PA)

J1640 Panhematin injection, hemin, 1 mg Medical

injection, heparin sodium, (heparin lock J1642 Medical flush), per 10 units

injection, heparin sodium, per 1000 J1644 Medical units

injection, dalteparin sodium, per 2500 J1645 Fragmin Either iu

J1650 Lovenox injection, enoxaparin sodium, 10 mg Either

J1652 Arixtra injection, fondaparinux sodium, 0.5 mg Either

injection, tetanus immune globulin, J1670 Hypertet Medical human, up to 250 units

injection, histrelin acetate, 10 Medical J1675 Supprelin mcgrograms (PA)

injection, hydrocortisone sodium J1720 Solu- Cortef Either succinate, up to 100 mg

injection, hydroxyprogesterone Pharmacy J1726 Makena caproate, (makena), 10 mg (PA)

Injection, hydroxyprogesterone Hydroxyprogesterone J1729 caproate, not otherwise specified, 10 Medical Caproate mg

J1738 Anjeso Injection, meloxicam, 1 mg Medical

Effective April 1, 2021 16

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

This Jcode is shared by two different dosage forms (both are ibandronate). Both products can be J1740 Boniva injection, ibandronate sodium, 1 mg Pharmacy billed via jcode (no PA required). Ibandronate vial is not covered on the pharmacy benefit.

J1741 injection, ibuprofen, 100 mg Medical

J1742 Corvert injection, ibutilide fumarate, 1 mg Medical

Medical J1743 Elaprase injection, idursulfase (PA)

Pharmacy J1744 Firazyr injection, icatibant, 1 mg (PA)

injection, infliximab, excludes May bill either benefit, PA required J1745 Remicade Either (PA) biosimilar, 10 mg regardless of benefit

Medical J1746 Trogarzo injection, ibalizumab-uiyk, 10 mg (PA)

J1750 Dexferrum, Infed injection, iron dextran, 50 mg Medical

J1756 Venofer injection, , 1 mg Medical

Medical J1786 Cerezyme injection, imiglucerase, 10 units (PA)

J1790 Inapsine injection, droperidol, up to 5 mg Medical

J1800 injection, propranolol hcl, up to 1 mg Medical

J1815 injection, insulin, per 5 units Medical

insulin for administration through dme J1817 Medical (i.e., insulin pump) per 50 units

Medical J1823 Uplizna Injection, inebilizumab-cdon, 1 mg (PA)

INJECTION, INTERFERON BETA-1A, 30 J1826 Avonex Pharmacy MCG

Effective April 1, 2021 17

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, interferon beta-1b, 0.25 mg (code may be used for medicare when Pharmacy J1830 Betaseron/ Extavia drug administered under the direct (PA) supervision of a physician, not for use when drug is self-administered)

J1833 Cresemba injection, isavuconazonium 1 mg Medical

injection, kanamycin sulfate, up to 500 J1840 Medical mg

J1850 injection, kanamycin sulfate,75 mg Medical

injection, ketorolac tromethamine, per J1885 Medical 15 mg

Medical J1930 Somatuline Depot injection, lanreotide (PA)

Medical J1931 Aldurazyme injection, laronidase (PA)

J1940 injection, furosemide, up to 20 mg Medical

May bill either benefit, PA required Injection, aripiprazole lauroxil, (aristada J1943 Aristada Initio Either when billing through pharmacy initio), 1 mg benefit

May bill either benefit, PA required Injection, aripiprazole lauroxil, J1944 Aristada Either when billing through pharmacy (aristada), 1 mg benefit

J1945 Refludan injection, lepirudin, 50 mg Medical

injection, leuprolide acetate (for depot Medical J1950 Lupron depot suspension), per 3.75 mg (PA)

J1953 Keppra injection, levetiracetam, 10 mg Medical

J1955 Carnitor injection, levocarnitine, per 1 g Medical

J1956 Levaquin injection, levofloxacin, 250 mg Medical

J1980 Levsin injection, hyoscyamine sulfate, 0.25mg Medical

injection, lidocaine hcl for intravenous J2001 Xylocaine Medical infusion, 10 mg

Effective April 1, 2021 18

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J2010 Lincocin injection, lincomycin hcl, up to 300 mg Medical

J2020 Zyvox injection, linezolid, 200 mg Medical

J2060 Ativan injection, lorazepam, 2 mg Medical

J2062 Adasuve loxapine, inhalation powder, 10 mg Medical

J2150 injection, mannitol, 25% in 50 ml Medical

Pharmacy J2170 Increlex injection, mescasermin (PA)

J2175 Demerol injection, meperidine hcl, per 100 mg Medical

Medical J2182 Nucala injection, mepolizumab, 1 mg (PA)

J2185 injection, meropenem, 100 mg Medical

injection, meropenem and J2186 Vabomere Medical vaborbactam, 10mg/10mg, (20mg)

injection, methylergonovine maleate, J2210 Methergine Medical up to 0.2 mg

Pharmacy J2212 Relistor injection, methylnaltrexone, 0.1 mg (PA)

J2250 injection, midazolam hcl, per 1 mg Medical

J2260 injection, milrinone lactate, 5 mg Medical

injection, morphine sulfate, up to 10 J2270 Medical mg

injection, morphine sulfate, J2274 Duramorph preservative free for epidural or Medical intrathecal use, 10 mg

J2278 Prialt injection, ziconotide, 1 mcg Medical

J2280 Avelox injection, moxifloxacin, 100 mg Medical

J2300 injection, nalbuphine hcl, per 10 mg Medical

J2310 injection, naloxone hcl, per 1 mg Either

Effective April 1, 2021 19

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J2315 Vivitrol injection, naltrexone, depot form, 1 mg Either

Medical J2323 Tysabri injection, natalizumab, 1 mg (PA)

J2325 Natrecor injection, nestiritide, 0.1mg Medical

Medical J2326 Spinraza injection, nusinersin, 0.1 mg (PA)

May bill either benefit, PA required J2350 Ocrevus injection, ocrelizumab, 1 mg Either (PA) regardless of benefit

injection, octreotide, depot form for Medical J2353 Sandostatin LAR intramuscular injection, 1 mg (PA)

injection, octreotide, nondepot form J2354 Sandostatin for subcutaneous or intravenous Medical injection, 25 mcg

J2355 Neumega injection, oprelvekin, 5 mg Medical

Medical J2357 Xolair injection, omalizumab, 5 mg (PA)

May bill either benefit, PA required J2358 Zyprexa Relprevv injection, olanzapine, long-acting, 1 mg Either when billing through pharmacy benefit

injection, orphenadrine citrate, up to J2360 Medical 60 mg

J2370 injection, phenylephrine hcl, up to 1 ml Medical

J2400 Nesacaine injection, chloroprocaine hcl, per 30 ml Medical

J2405 Zofran injection, ondansetron hcl, per 1 mg Medical

J2407 Orbactiv injection, oritavancin 10 mg Medical

J2410 Opana injection, oxymorphone hcl 1 mg Medical

J2425 Kepivance injection, palifermin, 50 mcg Medical

Effective April 1, 2021 20

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

May bill either benefit, PA required Invega Sustenna, J2426 injection, paliperidone palmitate Either when billing through pharmacy Invega Trinza benefit

injection, pamidronate disodium, per J2430 Aredia Medical 30 mg

J2469 Aloxi injection, palonosetron hcl, 25 mcg Medical

J2501 Zemplar injection, paricalcitol, 1 mcg Medical

Medical J2502 Signifor LAR inection, pasireotide long acting 1 mg (PA)

J2503 Macugen injection, pegaptanib sodium, 0.3 mg Medical

Medical J2504 Adagen injection, pegademase bovine, 25 iu (PA)

May bill either benefit, PA required Neulasta, Neulasta J2505 injection, pegfilgrastim, 6 mg Either when billing through pharmacy Onpro benefit

May bill either benefit, PA required J2507 Krystexxa injection, pegloticase, 1 mg Either (PA) regardless of benefit

injection, penicillin g procaine, J2510 Medical aqueous, up to 600,000 units

injection, pentobarbital sodium, per 50 J2515 Nembutal Medical mg

injection, penicillin g potassium, up to J2540 Pfizerpen-G Medical 600,000 units

injection, piperacillin J2543 Zosyn sodium/tazobactam sodium, 1 g/0.125 Medical g (1.125 g)

pentamidine isethionate, inhalation solution, fda-approved final product, J2545 Nebupent noncompounded, administered Medical through dme, unit dose form, per 300 mg

Effective April 1, 2021 21

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J2547 Rapivab injection, peramivir 1 mg Medical

injection, promethazine hcl, up to 50 J2550 Phenergan Medical mg

injection, phenobarbital sodium, up to J2560 Medical 120 mg

Medical J2562 Mozobil injection, plerixafor, 1 mg (PA)

J2590 Pitocin injection, oxytocin, up to 10 units Medical

injection, desmopressin acetate, per 1 J2597 Ddavp Medical mcg

J2675 injection, progesterone, per 50 mg Medical

injection, fluphenazine decanoate, up J2680 Medical to 25 mg

J2690 injection, procainamide hcl, up to 1 g Medical

J2700 injection, oxacillin sodium, 250 mg Medical

J2704 Diprivan injection , propofol, 10mg Medical

J2720 injection, protamine sulfate, per 10 mg Medical

injection, protein c concentrate, 10 J2724 Ceprotein Medical units

injection, pralidoxime chloride, up to 1 J2730 Medical g

injection, phentolamine mesylate, up to J2760 Medical 5 mg

injection, metoclopramide hcl, up to 10 J2765 Reglan Medical mg

injection, quinupristin/ dalfopristin, J2770 Synercid Medical 500mg

J2778 Lucentis injection, ranibizumab, 0.1 mg Medical

J2780 Zantac injection, ranitidine hcl, 25 mg Medical

Effective April 1, 2021 22

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J2783 Elitek injection, rasburicase, 0.5 mg Medical

J2785 Lexiscan injection, regadenoson, 0.1 mg Medical

Medical J2786 Cinqair injection, reslizumab, 1 mg (PA)

riboflavin 5' phosphate, opthalmic J2787 Photrexa Viscous Medical solution, up to 3ml

injection, rho d immune globulin, J2788 Micrhogam, Bayrho Medical human, minidose, 50 mcg (250 i.u.)

injection, rho d immune globulin, J2790 Rhogam ultra Medical human, full dose, 300 mcg (1500 i.u.)

injection, rho( d) immune globulin J2791 Rhophylac (human), (rhophylac), intramuscular or Medical intravenous, 100 iu

injection, rho d immune globulin, J2792 Winrho sdf intravenous, human, solvent detergent, Medical 100 iu

Pharmacy J2793 Arcalyst injection, rilonacept, 1 mg (PA)

May bill either benefit, PA required injection, risperidone, long acting, 0.5 J2794 Risperdal Consta Either when billing through pharmacy mg benefit

J2795 Naropin injection, ropivacaine hcl, 1 mg Medical

Medical J2796 Nplate injection, romiplostim, 10 mcg (PA)

J2797 Varubi injection, rolapitant, 0.5 mg Medical

May bill either benefit, PA required J2798 Perseris Injection, risperidone, (perseris), 0.5 mg Either when billing through pharmacy benefit

J2800 Robaxin injection, methocarbamol, up to 10 ml Medical

J2805 Sincalide injection, sincalide, 5 mcg Medical

J2810 injection, theophylline, per 40 mg Medical

Effective April 1, 2021 23

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, sargramostim (gm-csf), 50 J2820 Leukine Medical mcg

Medical J2840 Kanuma injection, sebelipase alfa, 1 mg (PA)

injection, secretin, synthetic, human, 1 J2850 Chirhostim Medical mcg

Medical J2860 Sylvant injection, siltuximab 10 mg (PA)

injection, sodium ferric gluconate J2916 Ferrlecit Medical complex in sucrose injection, 12.5 mg

injection, methylprednisolone sodium J2920 Solu- Medrol Either succinate, up to 40 mg

injection, methylprednisolone sodium J2930 Solu- Medrol Either succinate, up to 125 mg

Pharmacy J2940 Somatrem injection, somatrem, 1 mg (PA)

Genotropin, Humatrope, Norditropin, Nutropin, Pharmacy J2941 injection, somatropin, 1 mg Omnitrope, Saizen, (PA) Serostim, Zomacton, Zorbtive

injection, reteplase recombinant, J2993 Retavase Medical 18.1mg

J2997 Activase injection, alteplase recombinant, 1 mg Medical

J3010 Sublimaze injection, fentanyl citrate, 0.1 mg Medical

injection, sumatriptan succinate, 6 mg (code may be used for medicare when J3030 Imitrex drug administered under the direct Pharmacy supervision of a physician, not for use when drug is self-administered)

INJECTION FREMANEZUMAB-VFRM 1 Pharmacy J3031 Ajovy MG (PA)

Effective April 1, 2021 24

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Medical J3032 Vyepti Injection, eptinezumab-jjmr, 1 mg (PA)

Medical J3060 Elelyso injection, taliglucerate alfa, 10 units (PA)

J3070 Talwin injection, pentazocine, 30 mg Medical

J3090 Sivextro injection tedizolid phosphate 1 mg Medical

J3095 Vibrativ injection, telavancin, 10 mg Medical

J3101 Tnkase injection, tenecteplase, 1 mg Medical

injection, terbutaline sulfate, up to 1 J3105 Medical mg

Pharmacy J3110 Forteo injection, teriparatide, 10 mcg (PA)

Pharmacy J3111 Evenity Injection, romosozumab-aqqg, 1 mg (PA)

Pharmacy J3121 Delatestryl injection, testosterone enanthate, 1 mg (PA)

Medical J3145 Aveed Testosterone undecanoate 1mg (PA)

injection, chlorpromazine hcl, up to 50 J3230 Pharmacy mg

injection, thyrotropin alpha, 0.9 mg, J3240 Thyrogen Medical provided in 1.1 mg vial

Medical J3241 Tepezza Injection, teprotumumab-trbw, 10 mg (PA)

J3243 injection, tigecycline, 1 mg Medical

Medical J3245 Ilumya injection, tildrakizumab, 1 mg (PA)

J3246 Aggrastat injection, tirofiban hcl, 0.25mg Medical

injection, trimethobenzamide hcl, up to J3250 Tigan Medical 200 mg

Effective April 1, 2021 25

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, tobramycin sulfate, up to 80 J3260 Medical mg

May bill either benefit, PA required J3262 Actemra injection, tocilizumab, 1 mg Either (PA) regardless of benefit

Pharmacy J3285 Remodulin injection, treprostinil (PA)

injection, triamcinolone acetonide, J3300 Medical preservative free, 1 mg

injection, triamcinolone acetonide, not J3301 Kenalog Medical otherwise specified, 10 mg

injection, triamcinolone diacetate, per J3302 Clinacort Medical 5 mg

injection, triamcinolone hexacetonide, J3303 Aristospan Medical per 5 mg

injection, triamcinolone acetonide, Medical J3304 Zilretta preservative free extended release, (PA) microsphere formulation, 1 mg

Medical J3315 Trelstar injection, triptorelin pamoate, 3.75 mg (PA)

injection, triptorelin, extended release, Medical J3316 Triptodur 3.75 (PA)

J3355 Bravelle injection, urofollitropin, 75 iu Pharmacy

ustekinumab, for subcutaneous Pharmacy J3357 Stelara SC injection (PA)

ustekinumab, for intravenous injection, May bill either benefit, PA required J3358 Stelara IV Either (PA) 1 mg regardless of benefit

J3360 injection, diazepam, up to 5 mg Medical

J3365 Abbokinase injection, urokinase, 250,000 iu Medical

J3370 injection, vancomycin hcl, 500 mg Medical

Effective April 1, 2021 26

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Medical J3380 Entyvio injection vedolizumab 1 mg (PA)

Medical J3385 Vpriv injection, velaglucerase alfa, 100 units (PA)

J3396 Visudyne injection, verteporfin, 0.1 mg Medical

Medical J3397 Mepsevii inj, vestronidase alfa-vjbk, 1 mg (PA)

inj voretigene neparvovec-rzyl 1 billion Medical J3398 Luxturna vector genomes (PA)

Injection, onasemnogene abeparvovec- Medical J3399 Zolgensma xioi, per treatment, up to 5x10^15 (PA) vector genomes

J3410 injection, hydroxyzine hcl, up to 25 mg Medical

J3411 injection, thiamine hcl, 100 mg Medical

J3415 injection, pyridoxine hcl, 100 mg Medical

injection, vitamin b-12 , J3420 Medical up to 1,000 mcg

injection, phytonadione (vitamin k), per J3430 Medical 1 mg

J3465 Vfend injection, voriconazole, 10mg Medical

injection, hyaluronidase, up to 150 J3470 Amphadase Medical units

injection, hyaluronidase, ovine, J3471 preservative free, per 1 usp unit (up to Medical 999 usp units)

injection, hyaluronidase recombinant, 1 J3473 Medical usp unit

injection, magnesium sulfate, per 500 J3475 Medical mg

injection, potassium chloride, per 2 J3480 Medical meq

Effective April 1, 2021 27

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

May bill either benefit, PA required J3486 Geodon injection, ziprasidone mesylate, 10 mg Either when billing through pharmacy benefit

This Jcode is shared by two different products. Both products J3489 Reclast/Zometa injection, zoledronic acid, 1 mg Either can be billed via jcode (no PA required). Generic Zometa is not covered on the pharmacy benefit.

J3490 unclassified drugs Medical

drug administered through a metered J3535 Medical dose inhaler

J3585 Retrovir injection, zidovudine, 10 mg Medical

J3590 unclassified biologics Medical

unclassified drug or biological (for esrd J3591 Medical on dialysis)

infusion, normal saline solution, 1,000 J7030 sodium chloride Medical cc

infusion, normal saline solution, sterile J7040 sodium chloride Medical (500 ml=1 unit)

5% dextrose/normal saline (500 ml = 1 J7042 Dextrose- Nacl Medical unit)

J7050 sodium chloride infusion, normal saline solution, 250 cc Medical

J7060 dextrose 5% dextrose/water (500 ml = 1 unit) Medical

J7070 dextrose infusion, d-5-w, 1,000 cc Medical

infusion, dextran40, lmd 10% in 0.95 J7100 Medical sodium hcl, 500 ml

J7110 infusion, dextran 75 in d5w Medical

J7120 ringers lactate infusion, up to 1,000 cc Medical

J7121 5% dextrose lr infusion to 1000 cc Medical

Effective April 1, 2021 28

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Injection, coagulation factor xa J7169 Andexxa (recombinant), inactivated-zhzo Medical (andexxa), 10 mg

Medical J7170 Hemlibra inj emicizumab-kxwh, 0.5mg (PA)

J7175 Coagadex injection, factor x 1 i.u. (human) Medical

injection, human fibrinogen J7177 Fibryga Medical concentrate (fibryga), 1 mg

injection, human fibrinogen J7178 RiaSTAP concentrate, not otherwise specified, 1 Medical mg

injection von willebrand factor 1 i.u. J7179 Vonvendi Medical vwf:rco

injection, factor viii (antihemophilic J7180 Corifact Medical factor, human), 1 iu

injection, factor viii a-subunit, J7181 Tretten Medical (recombinant), per iu

injection, factor viii (antihemophilic J7182 NovoEight factor, recombinant), (novoeight), per Medical iu

injection, von willebrand factor J7183 WILATE Medical complex (human), wilate, 1 iu vwf:rco

Xyntha / Xyntha J7185 injection, xyntha, 1 iu Medical solofuse

injection, antihemophilic factor viii/von J7186 Alphanate willebrand factor complex (human), per Medical factor viii i.u.

injection, von willebrand factor J7187 Humate-P Medical complex (humate-p), per iu vwf-rc0

injection, factor viii (antihemophilic J7188 Obizur Medical factor, recombinant), (obizur), per i.u.

Effective April 1, 2021 29

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

factor viia (antihemophilic factor, J7189 Novoseven Medical recombinant) (novoseven rt), per 1 mcg

Hemofil-M, Koate, factor viii (antihemophilic factor, J7190 Medical Monoclate-P human) per i.u.

factor viii (antihemophilic factor J7191 Medical (porcine), per i.u.

Advate, Recombinate, factor viii (antihemophilic factor, J7192 Kogenate FS, Helixate recombinant) per iu, not otherwise Medical FS specified

Alphanine SD, factor ix (antihemophilic factor, J7193 Medical Mononine purified, non-recombinant) per i.u.

J7194 Profilnine factor ix complex, 1 iu Medical

J7195 Benefix, Ixinity factor ix recombinant, 1iu Medical

injection, antithrombin recombinant, J7196 Medical 50 i.u.

J7197 Thrombate iii injection, antithrombin iii, 1 iu Medical

anti-inhibitor, feiba vh immuno (anti- J7198 Feiba NF Medical inhibitor coagulant complex), 1iu

hemophilia clotting factor, not J7199 Medical otherwise classified

injection, factor ix, (antihemophilic J7200 Rixubis Medical factor, recombinant), (rixibus), per iu

injection, factor ix, fc fusion protein J7201 Alprolix Medical (recombinant), per iu

J7202 Idelvion injection, factor ix albumin fus prt 1 i.u. Medical

injection, factor ix (antihemophilic J7203 Rebinyn factor, recombinant), glycopegylated, Medical rebinyn, 1 i.u.

Injection, factor viii, antihemophilic J7204 Esperoct factor (recombinant), (esperoct), Medical glycopegylated-exei, per iu

Effective April 1, 2021 30

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J7205 Eloctate injection, factor viii fc fusion per iu Medical

J7207 Adynovate injection, factor viii pegylated 1 i.u. Medical

Injection, factor viii, (antihemophilic J7208 Jivi factor, recombinant), pegylated-aucl, Medical (jivi), 1 i.u.

J7209 Nuwiq injection, factor viii 1 i.u. Medical

injection, factor viii (antihemophilic J7210 Afstyla Medical factor, recombinant), (afstyla) 1 iu

injection, factor viii, (antihemophilic J7211 Kovaltry Medical factor, recombinant), (kovaltry), 1 iu

Factor viia (antihemophilic factor, J7212 Sevenfact recombinant)- jncw (sevenfact), 1 Medical microgram

contraceptive system, intrauterine, J7296 Kyleena Medical levonorgestrel releasing, 19.5 mg

J7297 Liletta lng-releasing iuc sys 52mg 3 yr dur Medical

J7298 Mirena lng-releasing iuc sys 52mg 5 yr dur Medical

paragard t380a (intrauterine copper J7300 Paragard Medical contraceptive)

levonorgestrel-releasing intrauterine J7301 Skyla Medical contraceptive system (skyla), 13.5 mg

contraceptive supply, hormone J7303 Nuva Ring Pharmacy retaining vaginal ring, each

contraceptive supply, hormone J7304 Contraceptive patch Pharmacy containing patch, each

aminolevulinic acid hcl for topical J7308 Levulan Kerastick administration, 20%, single unit dosage Medical form (354 mg)

Injection, fluocinolone acetonide, J7311 Retisert Medical intravitreal implant (retisert), 0.01 mg

Effective April 1, 2021 31

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, dexamethasone, intravitreal J7312 Ozurdex Medical implant, 0.1 mg

Injection, fluocinolone acetonide, J7313 Iluvien Medical intravitreal implant (Iluvien), 0.01 mg

Injection, fluocinolone acetonide, J7314 Yutiq Medical intravitreal implant (Yutiq), 0.01 mg

J7315 Mitosol mitomycin, opthalmic, 0.2 mg Medical

Medical J7316 Jetrea injection, ocriplasmin, 0.125 mg (PA)

hyaluronan or derivative, durolane, for Medical J7318 Durolane This HA product is not covered intra-articular injection, per dose (PA)

hyaluronan or derivitive, genvisc 850, Medical J7320 Genvisc 850 This HA product is not covered for intra-articular injection, 1 mg (PA)

Hyaluronan or derivative, hyalgan, Supartz/ Medical J7321 supartz OR Visco-3, for intra-articular This HA product is not covered Hyalgan/Visco-3 (PA) injection, per dose

hyaluronan or derivative for intra- Medical J7322 Hymovis This HA product is not covered articular injection, 1 mg (PA)

hyaluronan or derivative, euflexxa, for Medical J7323 Euflexxa This HA product is not covered intra-articular injection, per dose (PA)

hyaluronan or derivative, orthovisc, for Medical J7324 Orthovisc This HA product is not covered intra-articular injection, per dose (PA)

hyaluronan or derivative, synvisc or Medical J7325 Synvisc/ Synvisc-One synvisc-one, for intra-articular injection, This HA product is not covered (PA) 1 mg

hyaluronan or derivative, gel-one, for Medical J7326 Gel-One This HA product is not covered intra-articular injection, per dose (PA)

hyaluronan or derivative, monovisc, for Medical J7327 Monovisc This HA product is not covered intra-articular injection, per dose (PA)

hyaluronan or derivative, gelsyn-3, for Medical J7328 Gel-Syn This HA product is not covered intra-articular injection, 0.1 mg (PA)

Effective April 1, 2021 32

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

hyaluronan or derivative, trivisc, for Medical J7329 Trivisc This HA product is not covered intra-articular injection, 1 mg (PA)

J7330 Carticel implant, cultured chondrocytes, 1 ea Medical

Hyaluronan or derivative, synojoynt, for Medical J7331 Synojoynt This HA product is not covered intra-articular injection, 1 mg (PA)

Hyaluronan or derivative, triluron, for Medical J7332 Triluron This HA product is not covered intra-articular injection, 1 mg (PA)

Medical J7336 Qutenza capsaicin 8% patch, per sq cm (PA)

carbidopa 5 mg/levodopa 20 mg J7340 Duopa Medical enteral suspension, 100 ml

installation, ciprofloxacin otic J7342 Otiprio Medical suspension, 6mg

aminolevulinic acid hcl for topical J7345 Medical Ameluz administration, 10%,

Injection, bimatoprost, intracameral Medical J7351 Durysta implant, 1 microgram (PA)

Medical J7352 Scenesse Afamelanotide implant, 1 mg (PA)

Mometasone furoate sinus implant J7402 Sinuva Medical (sinuva), 10 micrograms

J7500 Imuran azathioprine, oral, 50 mg Pharmacy

J7501 azathioprine, parenteral, 100mg Medical

J7502 Sandimmune cyclosporine, oral, 100 mg Pharmacy

tacrolimus, extended release, (envarsus J7503 Envarsus XR Pharmacy xr), oral, 0.25 mg

injection, lymphocyte immune J7504 Atgam Medical globulin, 250mg

J7505 Orthoclone injection, monoclonal antibodies, 5 mg Medical

Effective April 1, 2021 33

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

tacrolimus, immediate release, oral, 1 J7507 Prograf Pharmacy mg

tacrolimus, extended release, (astagraf J7508 Astagraf XL Pharmacy xl), oral, 0.1 mg

J7509 Medrol methylprednisolone, oral, per 4 mg Pharmacy

J7510 Orapred prednisolone, oral, per 5 mg Pharmacy

lymphocyte immune globulin, J7511 Thymoglobulin antithymocyte globulin, rabbit, Medical parenteral, 25 mg

prednisone, immediate release or J7512 Prednisone Pharmacy delayed release, oral, 1 mg

J7513 Zenapax daclizumab, parenteral, 25 mg Medical

J7515 Gengraf, Neoral cyclosporine, oral, 25 mg Pharmacy

J7516 Sandimmune parenteral, cyclosporine, 250 mg Medical

J7517 Cellcept mycophenolate mofetil, oral, 250 mg Pharmacy

J7518 Myfortic mycophenolic acid, oral, 180 mg Pharmacy

J7520 Rapamune oral, sirolimus, 1 mg Pharmacy

J7525 Prograf injection, tacrolimus, 5mg Medical

J7527 Zortress everolimus, oral, 0.25 mg Pharmacy

arformoterol, inhalation solution, fda approved final product, J7605 Arformoterol Pharmacy noncompounded, administered through dme, unit dose form, 15 mcg

levalbuterol, inhalation solution, compounded product, administered J7607 Perforomist Pharmacy through dme, concentrated form, 0.5 mg

acetylcysteine, inhalation solution, fda- approved final product, J7608 Acetylcysteine Medical noncompounded, administered through dme, unit dose form, per g

Effective April 1, 2021 34

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

albuterol, inhalation solution, fda- approved final product, J7611 Pharmacy noncompounded, administered through dme, concentrated form, 1 mg

levalbuterol, inhalation solution, fda- approved final product, J7612 Xopenex noncompounded, administered Pharmacy through dme, concentrated form, 0.5 mg

albuterol, inhalation solution, fda- approved final product, J7613 Accuneb Pharmacy noncompounded, administered through dme, unit dose, 1 mg

levalbuterol, inhalation solution, fda- approved final product, J7614 Xopenex Pharmacy noncompounded, administered through dme, unit dose, 0.5 mg

albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, fda-approved J7620 Pharmacy final product, noncompounded, administered through dme

budesonide, inhalation solution, fda- approved final product, J7626 Pulmicort noncompounded, administered Pharmacy through dme, unit dose form, up to 0.5 mg

J7631 cromolyn sodium noncomp unit, 10 mg Pharmacy

dornase alfa, inhalation solution, fda- approved final product, Pharmacy J7639 Pulmozyme noncompounded, administered (PA) through dme, unit dose form, per mg

glycopyrrolate, inhalation solution, J7643 compounded product, administered Pharmacy through dme, unit dose form, per mg

Effective April 1, 2021 35

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

ipratropium bromide, inhalation solution, fda-approved final product, J7644 Pharmacy noncompounded, administered through dme, unit dose form, per mg

mannitol, administered thru an inhaler, J7665 Aridol Medical 5 mg

meterproterenol sulfate non- comp J7669 Medical unit, 10 mg

methacholine chloride administered as J7674 Provocholine inhalation solution through a nebulizer, Medical per 1 mg

Revefenacin inhalation solution, fda- approved final product, non- J7677 Yupelri Either compounded, administered through DME, 1 microgram

tobramycin, inhalation solution, fda- approved final product, J7682 Tobi Pharmacy noncompounded, unit dose form, administered through dme, per 300 mg

Pharmacy J7686 Tyvaso treprosinil, non-comp unit (PA)

noc drugs, inhalation solution J7699 Medical administered through dme

noc drugs, other than inhalation drugs, J7799 Medical administered through dme

J7999 compounded drug noc Medical

anti-emetic drug, rectal suppository, J8498 Medical not otherwise specified

prescription drug, oral, Pharmacy J8499 nonchemotherapeutic, nos (PA)

J8501 Emend aprepitant, oral, 5 mg Pharmacy

Pharmacy J8510 Myleran busulfan, oral, 2 mg (PA)

Effective April 1, 2021 36

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J8515 Dostinex cabergoline, oral, 0.25 mg Pharmacy

Pharmacy J8520 Xeloda capecitabine, oral, 150 mg (PA)

Pharmacy J8521 Xeloda capecitabine, oral, 500 mg (PA)

Pharmacy J8530 Cytoxan oral, cyclophophamide 25 mg (PA)

J8540 dexamethasone, oral, 0.25 mg Pharmacy

Pharmacy J8560 Etoposide etoposide, oral, 50 mg (PA)

Pharmacy J8562 Oforta fludarabine phosphate, oral, 10 mg (PA)

Pharmacy J8565 Iressa gefitinib, oral, 250 mg (PA)

antiemetic drug, oral, not otherwise Pharmacy J8597 specified (PA)

J8600 Alkeran melphalan, oral, 2 mg Pharmacy

J8610 methotrexate, oral, 2.5 mg Pharmacy

J8650 Cesamet nabilone, oral, 1 mg Pharmacy

netupitant 300 mg and palonosetron J8655 Akynzeo Pharmacy 0.5 mg, oral

J8670 Varubi rolapitant, oral, 1 mg Pharmacy

Pharmacy J8700 Temodar temozolomide, oral, 5 mg (PA)

Pharmacy J8705 Hycamtin topotecan, oral, 0.25 mg (PA)

prescription drug, oral, Pharmacy J8999 chemotherapeutic, nos (PA)

J9000 Adriamycin injection, doxorubicin hcl, 10 mg Medical

Effective April 1, 2021 37

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J9015 Proleukin injection, aldesleukin, 1 ea Medical

J9017 Trisenox injection, arsenic trioxide, 1 mg Medical

injection, asparaginase (erwinaze), J9019 Erwinaze Medical 1,000 iu

J9020 Elspar injection, asparaginase, 10,000 units Medical

J9022 Tecentriq injection, atezolizumab, 10 mg Medical

J9023 Bavencio injection, avelumab, 10 mg Medical

J9025 Vidaza injection, azacitidine, 1 mg Medical

J9027 Clolar injection, clofarabine, 1 mg Medical

J9030 TheraCys, TiceBCG BCG live intravesical instillation, 1 mg Medical

J9032 Beleodaq injection belinostat 10 mg Medical

Injection, bendamustine hcl J9033 Treanda Medical (treanda), 1 mg

Injection, bendamustine hcl J9034 Bendeka Medical (bendeka), 1 mg

J9035 Avastin injection, bevacizumab, 10 mg Medical

Injection, bendamustine J9036 Belrapzo hydrochloride, Medical (belrapzo/bendamustine), 1 mg

injection, belantamab mafodontin- J9037 Blenrep Medical blmf, 0.5 mg

J9039 Blincyto injection, blinatumomab 1 microgram Medical

J9040 injection, bleomycin sulfate, 15 units Medical

J9041 Velcade injection, bortezomib, 0.1 mg Medical

J9042 Adcetris injection, brentuximab vedotin, 1 mg Medical

J9043 Jevtana injection, cabazitaxel, 1 mg Medical

injection, bortezomib, not otherwise J9044 Medical specified, 0.1 mg

Effective April 1, 2021 38

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J9045 injection, carboplatin, 50 mg Medical

J9047 Kyprolis injection, carfilzomib, 1mg Medical

J9050 BICNU injection, carmustine, 100mg Medical

J9055 Erbitux injection, cetuximab, 10 mg Medical

J9057 Aliqopa injection copanlisib, 1 mg Medical

J9060 cisplatin, powder or solution, per 10 mg Medical

J9065 Leustatin injection, cladribine, per 1 mg Medical

J9070 injection, cyclophosphamide, 100 mg Medical

J9098 Depocyt injection, cytarabine liposome, 10 mg Medical

J9100 injection, cytarabine, 100 mg Medical

Injection, calaspargase pegol-mknl, 10 J9118 Asparlas Medical units

J9119 Libtayo Injection, cemiplimab-rwlc, 1 mg Medical

J9120 Cosmegan injection, dactinomycin, 0.5 mg Medical

J9130 injection, dacarbazine, 100 mg Medical

Injection, daratumumab, 10 mg and J9144 Darzalex Faspro Medical hyaluronidase-fihj

J9145 Darzalex injection, daratumumab 10mg Medical

J9150 Cerubidine injection, daunorubicin, 10 mg Medical

injection, daunorubicin citrate, J9151 Medical liposomal formulation, 10 mg

injection, liposomal, 1 mg daunorubicin J9153 Vyxeos Medical and 2.27 mg cytarabine

J9155 Firmagon injection, degarelix, 1 mg Medical

J9160 Ontak injection, denileukin diftitox, 300 mcg Medical

J9171 Taxotere injection, docetaxel, 1 mg Medical

J9173 Imfinzi injection, durvalumab, 10 mg Medical

Effective April 1, 2021 39

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J9176 Empliciti injection, elotuzumab 1mg Medical

Injection, enfortumab vedotin-ejfv, 0.25 J9177 Padcev Medical mg

J9178 injection, epirubicin hcl, 2 mg Medical

J9179 Halaven injection, erbulin mesylate, 0.1 mg Medical

J9181 injection, etoposide, 10 mg Medical

J9185 injection, fludarabine phosphate, 50 mg Medical

J9190 Adrucil injection, fluorouracil, 500 mg Medical

Injection, gemcitabine hydrochloride, J9198 Infugem Medical (infugem), 100 mg

J9200 injection, floxuridine, 500 mg Medical

J9201 Gemzar injection, gemcitabine hcl, 200 mg Medical

Medical J9202 Zoladex goserelin acetate implant, per 3.6 mg (PA)

injection, gemtuzumab ozogamicin, 0.1 J9203 Mylotarg Medical mg (mylotarg)

J9204 Poteligeo Injection, mogamulizumab-kpkc, 1 mg Medical

J9205 Onivyde injection, irinotecan liposome, 1mg Medical

J9206 Camptosar injection, irinotecan, 20 mg Medical

J9207 Ixempra injection, ixabepilone, 1 mg Medical

J9208 Ifex injection, ifosfamide, 1 g Medical

J9209 injection, mesna, 200 mg Medical

Medical J9210 Gamifant Injection, emapalumab-lzsg, 1 mg (PA)

J9211 Idamycin injection, idarubicin hcl, 5 mg Medical

Pegasys, Pegasys injection, interferon-alfacon-1, J9212 Medical ProClick recombinant, 1 microgram

Effective April 1, 2021 40

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Roferon A, Interferon injection, interferon, alfa-2a, J9213 Medical alfa-2a inj recombinant, 3 million units

injection, interferon, alfa-2b, J9214 Intron A Medical recombinant, 1 million units

injection, interferon, alfa-n3, (human J9215 Alferon- N interferon Medical leukocyte derived), 250,000 iu

injection, interferon, gamma 1-b, 3 Pharmacy J9216 Actimmune million units (PA)

leuprolide acetate (for depot Medical J9217 Eligard/Lupron depot suspension), 7.5 mg (PA)

injection, non depot form for sc or iv Pharmacy J9218 Lupron non-depot use, leuprolide acetate, per 1 mg (PA)

J9219 Viadur leuprolide acetate implant, 65 mg Medical

J9223 Zepzelca Injection, lurbinectedin, 0.1 mg Medical

Medical J9225 Vantas histrelin implant (vantas), 50 mg (PA)

Medical J9226 Supprelin LA histrelin implant (supprelin la), 50 mg (PA)

J9227 Sarclisa Injection, isatuximab-irfc, 10 mg Medical

J9228 Yervoy injection, ipilumumab, 1 mg Medical

injection, inotuzumab ozogamicin, 0.1 J9229 Besponsa Medical mg

J9230 Mustargen injection, mechlorethamine hcl, 10 mg Medical

Injection, melphalan hydrochloride, not J9245 Alkeran Medical otherwise specified, 50 mg

J9246 Evomela Injection, melphalan (evomela), 1 mg Medical

J9250 methotrexate sodium, 5 mg Medical

J9260 methotrexate sodium, 50 mg Medical

J9261 Arranon injection, nelarbine, 50 mg Medical

Effective April 1, 2021 41

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

injection, omacetaxine mepesuccinate, J9262 Synribo Medical 0.01 mg

J9263 Eloxatin injection, oxaliplatin, 0.5 mg Medical

injection, paclitaxel protein-bound J9264 Abraxane Medical particles, 1 mg

injection, pegaspargase, per single dose J9266 Oncaspar Medical vial

J9267 Nov-Onxol injection, paclitaxel, 1 mg Medical

J9268 Nipent injection, pentostatin, 10 mg Medical

Injection, tagraxofusp-erzs, 10 J9269 Elzonris Medical micrograms

J9270 injection, plicamycin, 2.5 mg Medical

J9271 Keytruda injection, pembrolizumab, 1 mg Medical

J9280 injection, mitomycin, 5 mg Medical

Mitomycin pyelocalyceal instillation, 1 J9281 Jelmyto Medical mg

injection, olaratumumab, 10 mg J9285 Lartruvo Medical (lartruvo)

J9293 injection, mitoxantrone hcl, per 5 mg Medical

J9295 Portrazza injection, necitumumab, 1 mg Medical

J9299 Opdivo injection nivolumab, 1 mg Medical

J9301 Gazyva injection, obinutuzumab, 10 mg Medical

J9302 Arzerra injection, ofatumumab, 10 mg Medical

J9303 Vectibix injection, panitumumab, 10 mg Medical

Injection, pemetrexed (PEMFEXY), 10 J9304 Pemfexy Medical mg

Injection, pemetrexed, not otherwise J9305 Alimta Medical specified, 10 mg

Effective April 1, 2021 42

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J9306 Perjeta injection, pertuzumab, 1 mg Medical

J9307 Folotyn injection, pralatrexate, 1 mg Medical

J9308 Cyramza injection ramucirumab 5 mg Medical

Injection, polatuzumab vedotin-piiq, 1 J9309 Polivy Medical mg

injection, rituximab and hyaluronidase, May bill either benefit, PA required J9311 Rituxan Hycela Either (PA) 10 mg regardless of benefit

May bill either benefit, PA required J9312 Rituxan injection, rituximab, 10 mg Either (PA) regardless of benefit

Injection, moxetumomab pasudotox- J9313 Lumoxiti Medical tdfk, 0.01 mg

J9315 Istodax injection, romidepsin, 1 mg Medical

Injection, pertuzumab, trastuzumab, J9316 Phesgo Medical and hyaluronidase-zzxf, per 10 mg

Injection, sacituzumab govitecan-hziy, J9317 Trodelvy Medical 2.5 mg

J9320 Zansosar injection, streptozocin, 1 g Medical

injection, talimogene laherparepvec, J9325 Imlygic Medical per 1 million plaque forming units

J9328 Temodar IV injection, temozolomide, 1 mg Medical

J9330 Torisel injection, temsirolimus, 1 mg Medical

J9340 injection, thiotepa, 15 mg Medical

J9349 Monjuvi injection, tafasitamab-cxix, 2 mg Medical

J9351 Hycamptin injection, topotecan, 0.1 mg Medical

J9352 Yondelis injection, trabectedin 0.1mg Medical

injection, ado-trastuzumab emtansine, J9354 Kadcyla Medical 1 mg

Effective April 1, 2021 43

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

J9355 Herceptin injection, trastuzumab, 10 mg Medical

Injection, trastuzumab, 10 mg and J9356 Herceptin Hylecta Medical Hyaluronidase-oysk

injection, valrubicin, intravesical, 200 J9357 Valstar Medical mg

Injection, fam-trastuzumab deruxtecan- J9358 Enhertu Medical nxki, 1 mg

J9360 injection, vinblastine sulfate, 1 mg Medical

J9370 vincristine sulfate, 1 mg Medical

injection, vincristine sulfate liposome, 1 J9371 Marquibo Medical mg

J9390 Navelbine injection, vinorelbine tartrate, 10 mg Medical

J9395 Faslodex injection, fulvestrant, 25 mg Medical

J9400 Zaltrap injection, ziv-aflibercept, 1 mg Medical

not otherwise classified, antineoplastic J9999 Medical drugs

injection, ferumoxytol, for treatment of Q0138 Fereheme iron deficiency , 1 mg (non-esrd Medical use)

chlorpromazine hydrochloride, 5 mg, oral, fda approved prescription anti- emetic, for use as a complete Q0161 Chlorpromazine therapeutic substitute for an iv anti- Pharmacy emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

injection, fosphenytoin, 50 mg Q2009 Medical phenytoin equivalent

influenza virus vaccine, split virus, when administered to individuals 3 years of Q2035 Afluria Either age and older, for intramuscular use (afluria)

Effective April 1, 2021 44

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

influenza virus vaccine, split virus, when administered to individuals 3 years of Q2037 Fluvirin Either age and older, for intramuscular use (fluvirin)

influenza virus vaccine, split virus, when administered to individuals 3 years of Q2038 Fluzone Either age and older, for intramuscular use (fluzone)

tisagenlecleucel, up to 250 million car positive viable t cells, including Medical Q2040 Kymriah leukapheresis and dose preparation (PA) procedures, per infusion

axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car t cells, Medical Q2041 Yescarta including leukapheresis and dose (PA) preparation procedures, per infusion

tisagenlecleucel, up to 600 million car- positive viable t cells, including Medical Q2042 Kymriah leukapheresis and dose preparation (PA) procedures, per therapeutic dose

Medical Q2043 Provenge sipuleucel-t auto cd54+ (PA)

injection, doxorubicin hydrochloride, Q2050 Lipodox liposomal, not otherwise specified, 10 Medical mg

Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car Medical Q2053 Tecartus positive viable t cells, including (PA) leukapheresis and dose preparation procedures, per therapeutic dose

INJECTION, INTERFERON BETA-1A, 1 Q3027 Avonex Pharmacy MCG FOR INTRAMUSCULAR USE

injection, interferon beta-1a, 1 mcg for Pharmacy Q3028 Rebif subcutaneous use (PA)

Effective April 1, 2021 45

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

iloprost, inhalation solution, fda- approved final product, non- Pharmacy Q4074 Ventavis compounded, administered through (PA) dme, unit dose form, up to 20 micrograms

May bill either benefit, PA required injection, filgrastim-sndz, biosimilar, Q5101 Zarxio Either when billing through pharmacy (zarxio) 1 microgram benefit

injection , infliximab-dyyb , biosimilar, May bill either benefit, PA required Q5103 Inflectra Either (PA) 10 mg regardless of benefit

injection, infliximab-abda, biosimilar, May bill either benefit, PA required Q5104 Renflexis Either (PA) (renflexis), 10 mg regardless of benefit

May bill either benefit, PA required injection, epoetin alfa, biosimilar, Q5105 Retacrit Either when billing through pharmacy (retacrit) (for esrd on dialysis), 100 units benefit

May bill either benefit, PA required injection, epoetin alfa, biosimilar, Q5106 Retacrit Either when billing through pharmacy (Retacrit) (for non-esrd use), 1000 units benefit

injection, bevacizumab-awwb, Q5107 Mvasi Medical biosimilar, (mvasi), 10 mg

May bill either benefit, PA required injection, pegfilgrastim-jmdb biosimilar, Q5108 Fulphila Either when billing through pharmacy (fuphila), 0.5 mg benefit

injection, infliximab-qbtx, biosimilar, May bill either benefit, PA required Q5109 Ixifi Either (PA) (ixifi), 10 mg regardless of benefit

May bill either benefit, PA required injection, filgrastim-aafi, biosimilar, Q5110 Nivestym Either when billing through pharmacy (nivestym), 1 microgram benefit

May bill either benefit, PA required injection, pegfilgrastim-cbqv, biosimilar, Q5111 Udenyca Either when billing through pharmacy (udenyca), 0.5 mg benefit

Effective April 1, 2021 46

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Injection, trastuzumab-dttb, biosimilar, Q5112 Ontruzant Medical (Ontruzant), 10 mg

Injection, trastuzumab-pkrb, biosimilar, Q5113 Herzuma Medical (Herzuma), 10 mg

Injection, Trastuzumab-dkst, biosimilar, Q5114 Ogivri Medical (Ogivri), 10 mg

May bill either benefit, PA required Q5115 Truxima Inj truxima 10 mg Either (PA) regardless of benefit

Injection, trastuzumab-qyyp, biosimilar, Q5116 Trazimera Medical (trazimera), 10 mg

Injection, trastuzumab-anns, biosimilar, Q5117 Kanjinti Medical (kanjinti), 10 mg

InjInjection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mgection, Q5118 Zirabev Medical bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg

Injection, rituximab-pvvr, biosimilar, May bill either benefit, PA required Q5119 Ruxience Either (PA) (ruxience), 10 mg regardless of benefit

Injection, pegfilgrastim-bmez, Q5120 Ziextenzo Medical biosimilar, (ziextenzo), 0.5 mg

Injection, infliximab-axxq, biosimilar, May bill either benefit, PA required Q5121 Avsola Either (PA) (avsola), 10 mg regardless of benefit

May bill either benefit, PA required Injection, pegfilgrastim-apgf, biosimilar, Q5122 Nyvepria Either when billing through pharmacy (nyvepria), 0.5 mg benefit

injection, buprenorphine extended Medical Q9991 Sublocade release < 100 mg (PA)

injection, buprenorphine extended Medical Q9992 Sublocade release > 100 mg (PA)

butorphanol tartrate, nasal spray, 25 S0012 Stadol Pharmacy mg

Effective April 1, 2021 47

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

May bill either benefit, PA required S0013 Spravato Esketamine, nasal spray, 1 mg Either (PA) regardless of benefit

S0014 Cognex tacrine hydrochloride, 10 mg Pharmacy

Pharmacy S0088 Gleevec imatinib, 100 mg (PA)

S0090 Viagra sildenafil citrate, 25 mg Pharmacy

granisetron hydrochloride,1 mg (for S0091 Kytril circumstances falling under the Pharmacy medicare stature use q0166)

S0104 Retrovir zidovudine, oral, 100 mg Pharmacy

bupropion hcl sustained release tab, S0106 Wellbutrin SR Pharmacy 150 mg, per bottle of 60

S0108 Purinethol mercaptopurine, oral, 50 mg Pharmacy

S0109 Dolophine methadone, oral, 5 mg Pharmacy

S0117 Retin A/Atralin/Renova tretinoin, topical, 5 grams Pharmacy

S0119 Zofran ondansetron, oral 4 mg Pharmacy

S0122 Menopur injection, menotropins, 75 iu Pharmacy

S0136 Clozaril clozapine, 25 mg Pharmacy

S0137 Videx didanosine (ddl), 25 mg Pharmacy

S0138 Propecia finasteride, 25 mg Pharmacy

S0139 Rogaine, Loniten minoxidil, 10 mg Pharmacy

S0140 Invirase saquinavir, 200 mg Pharmacy

injection, pegylated interferon alfa 2a, Pharmacy S0145 Pegasys 180 mcg per 0.5 ml (PA)

Pharmacy S0148 Peg-Intron injection, peginterferon alfa-2b (PA)

S0156 Aromasin exemestane, 25 mg Pharmacy

Effective April 1, 2021 48

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

S0157 Regranex becaplermin gel, 0.02%, 0.5g Pharmacy

S0160 Dexedrine dextroamphetamine sulfate, 5 mg Pharmacy

S0170 Arimidex anastrazole, oral, 1 mg Pharmacy

S0172 Leukeran chlorambucil, oral, 2 mg Pharmacy

dolasetron mesylate , oral 50 mg (for S0174 Anzemet circumstances falling under medicare Pharmacy statute)

S0175 Drogenil flutamide, oral, 125 mg Pharmacy

S0176 Hydrea hydroxyurea, oral, 500 mg Pharmacy

S0178 Ceenu lomustine, oral, 10 mg Pharmacy

S0179 Megase megesterol acetate, oral 20 mg Pharmacy

procarbazine maleate, oral, 5 mg (for S0182 Matulane circumstances foalling undr the Pharmacy medicare stature use q0164-q0165)

S0183 Compazine prochlorperazine maleate, oral, 5mg Pharmacy

S0187 Nolvadex tamoxifen citrate, oral, 10 mg Pharmacy

Medical S0189 Testopel testosterone pellet, 75 mg (PA)

dialysis/stress vitamin supplement, S0194 Pharmacy oral, 100 mg capsules

prenatal vitamins, 30 day supply S0197 Pharmacy (further documentation required)

Stent, non-coronary, temporary, with S1091 Propel Medical delivery system (propel)

nicotine patches, legend (further S4990 Nicoderm CQ, Nicotrol Pharmacy documentation required)

S4995 Nicorette smoking cessation gum Pharmacy

Prescription drug , S5000 Pharmacy generic

Effective April 1, 2021 49

CCHP

Code Brand Name Description (PA) = Prior Authorization required Benefit Notes

Prescription drug , S5001 Pharmacy brand name

Effective April 1, 2021 50