Authorization Requirements for Medications Under
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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