The following medications, typically administered in a provider's office or ambulatory/outpatient infusion center, require authorization prior to utilization. Authorization requests can be submitted via the Portal. Additionally, you are welcome to call our member services line to initiate the Prior Authorization process. This list is updated quaterly. Effective date: 1/1/2021
Therapeutic category Brand Name Generic Name HCPCS Immunologic agent Orencia, IV infusion abatacept J0129 Botulinum toxins Dysport abobotulinumtoxin B J0586 HER-2 receptor drug Kadcyla ado-trastuzumab emtansine J9354 Ophthalmic injectable Eylea afilbercept J0178 Enzyme replacement drug Fabrazyme agalsidase beta J0180 Multiple sclerosis drug Lemtrada alemtuzumab J0202 Enzyme replacement drug Lumizyme alglucosidase alfa J0221 Enzyme replacement drug Strensiq asfotase alfa J3590 (non-specific) PD1-PDL1 drug Tecentriq atezolizumab J9022 PD1-PDL1 drug Bavencio avelumab J9023 CAR-T Therapy Yescarta axicabtageneciloleucel inpatient admin Systemic lupus erythematosus (SLE) drug Benlysta belimumab J0490 Antineoplastic agent Beleodaq belinostat J9032 Antineoplastic Belrapzo bendamustine HCl J9036 Antineoplastic Bendeka bendamustine HCl J9034 Antineoplastic agent Treanda bendamustine HCl J9033 Respiratory injectable Fasenra benralizumab J0517
J9035/J3590 (ophthalmology Antineoplastic Avastin bevacizumab uses this non-specific code) Antineoplastic agent Mvasi bevacizumab-awwb Q5107 Antineoplastic agent Zirabev bevacizumab-bvzr Q5118 Antineoplastic agent Blincyto blinatumomab J9039 Antineoplastic Adcetris brentuximab vedotin J9042 Ophthalmic injectable Beovu brolucizumab-dbll J0179 Hereditary angioedema medication Berinert C1 esterase inhibitor J0597 Hereditary angioedema medication Cinryze C1 esterase inhibitor J0598 Hereditary angioedema medication Haegarda C1 esterase inhibitor J0599 Hereditary angioedema medication Ruconest C1 esterase inhibitor J0596 Antineoplastic agent Jevtana cabazitaxel J9043 Antineoplastic agent Kyprolis carfilzomib J9047 PD1-PDL1 drug Libtayo cemiplimab-rwlc J9119 Enzyme replacement drug Brineura cerliponse alfa J0567 Antineoplastic Erbitux cetuximab J9055 Adrenocorticotropin Stimulating Hormone Acthar HP corticotropin J0800 Antineoplastic Darzalex daratumumab J9145 Antineoplastic Darzalex Faspro daratumumab and hyaluronidase-fihj J9144 Erythropoiesis stimulating agent Aranesp darbepoetin alfa J0881 (non-dialysis) Erythropoiesis stimulating agent Aranesp darbepoetin alfa J0882 (dialysis, ESRD) Osteoporosis drug Prolia denosumab J0897 Bone modifying agent Xgeva denosumab J0897 PD1-PDL1 drug Imfinzi durvalumab J9173 Hereditary angioedema medication Kalbitor ecallantie J1290 Complement Inhibitor, monoclonal antibody Soliris eculizumab J1300 Amyotrophic lateral sclerosis (ALS) drug Radicava edaravone J1301 Enzyme replacement drug Vimizim elosulfase alfa J1322 Antineoplastic Empliciti elotuzumab J9176 Antineoplastic agent Padcev enfortumab vedotin J9177 Erythropoiesis stimulating agent Epogen epoetin alfa J0885 (non-dialysis) Erythropoiesis stimulating agent Epogen epoetin alfa J0886 (dialysis, ESRD) Erythropoiesis stimulating agent Mircera epoetin alfa J0888(non-dialysis) Erythropoiesis stimulating agent Mircera epoetin alfa J0887 (dialysis, ESRD) Erythropoiesis stimulating agent Procrit epoetin alfa J0885 (non-dialysis) Erythropoiesis stimulating agent Procrit epoetin alfa J0886 (dialysis, ESRD) Pulmonary artierial hypertension drug Flolan, IV infusion epoprostenol sodium J1325 Pulmonary artierial hypertension drug Veletri epoprostenol sodium J1325 Migraine prophylaxis Vyepti eptinezumab-jjmr J3032 Antineoplastic agent Halaven eribulin J9179
G2082 (<56mg)/G2083 Antidepressant Spravato esketamine, intranasal (>56mg) (J3490 non-specific) Muscular dystrophy drug Exondys 51 eteplirsen J1428 HER-2 receptor drug Enhertu fam-trastuzumab deruxtecan-nxki J9358 Iron product Injectafer ferric carboxymaltose J1439 Iron product Monoferric ferric derisomaltose J1437
Iron product Feraheme ferric gluconate Q0138 (ND)/Q0139 (dialysis) Granulocyte-colony stimulating factor Granix filgrastim J1447 Granulocyte-colony stimulating factor Neupogen filgrastim J1442 Granulocyte-colony stimulating factor Nivestym filgrastim Q5110 Granulocyte-colony stimulating factor Zarxio filgrastim Q5101 Enzyme replacement drug Naglazyme galsulfase J1458 Immunologic agent Simponi Aria, IV infusion golimumab J1602 Gonadtropin-releasing hormone agonist Zoladex goserelin J9202 Antiemetics, IV admin Sustol granisetron, extended-release J1627 Hyaluronic Acid agents Hymovis hyaluronan J7322 Hyaluronic Acid agents Monovisc hyaluronan J7327 Hyaluronic Acid agents Orthovisc hyaluronan J7324 Hyaluronic Acid agents Synojoynt hyaluronate derivative J7331 Hyaluronic Acid agents Triluron hyaluronate derivative J7332 Hyaluronic Acid agents TriVisc hyaluronate derivative J7329 Hyaluronic Acid agents Gel-One hyaluronate, cross-linked J7326 Hyaluronic Acid agents Synvisc/Synvisc-One hylan polymer A and B J7325 Hereditary angioedema medication Firazyr icatibant J1744 Enzyme replacement drug Elaprase idursulfase J1743 Antineoplastic agent Yervoy ilipmumab J9228 Enzyme replacement drug Cerezyme imiglucerase J1786 Immunoglobulin Asceniv immune globulin J1554 (*new 4/1/21) Immunoglobulin Bivigam immune globulin J1556 Immunoglobulin Carimune NF immune globulin J1566 Immunoglobulin Cutaquig SC immune globulin J3590 (non-specific) Immunoglobulin Flebogamma immune globulin J1572 Immunoglobulin Gammagard, Gammagard S/Dimmune globulin J1569 Immunoglobulin Gammaked immune globulin (IV or SC) J1561 Immunoglobulin Gammaplex immune globulin J1557 Immunoglobulin Gamunex-C immune globulin J1561 Immunoglobulin Hizentra SC immune globulin J1559 Immunoglobulin HyQvia SC immune globulin J1575 Immunoglobulin Octagam immune globulin J1568 Immunoglobulin Panzyga immune globulin J1599 Immunoglobulin Privigen immune globulin J1459 Immunoglobulin Xembify SC immune globulin J1558 Botulinum toxins Xeomin incobotulinumtoxin A J0588 Immunologic agent Remicade infliximab J1745 Immunologic agent Renflexis infliximab-abda Q5104 Immunologic agent Avsola infliximab-axxq Q5121 Immunologic agent Inflectra infliximab-dyyb Q5103 Antineoplastic Besponsa inotuzumab ozogamicin J9229 Antineoplastic agent Onivyde irinotecan liposome J9205 Antineoplastic agent Sarclisa isatuximab-irfc J9999 (non-specific) Hereditary angioedema medication Takhzyro lanadelumab J0593 Enzyme replacement drug Aldurazyme laronidate J1931 Gonadtropin-releasing hormone agonist Eligard leuprolide J9217 Gonadtropin-releasing hormone agonist Lupron Depot leuprolide J1950 Antineoplastic, rescue agent Fusilev levoleucovorin J0641 Antineoplastic, rescue agent Khapzory levoleucovorin J0642 Intrauterine device, contraceptive Kyleena levonorgestrel intrauterine device J7296 Intrauterine device, contraceptive Liletta levonorgestrel intrauterine device J7297 Intrauterine device, contraceptive Mirena levonorgestrel intrauterine device J7298 Intrauterine device, contraceptive Skyla levonorgestrel intrauterine device J7301 Respiratory injectable Nucala mepolizumab J2182 Antineoplastic agent Lumoxiti moxetumomab pasudotox-tdfk J9313 Multiple sclerosis drug Tysabri natalizumab J2323 Antineoplastic agent Portrazza necitumumab J9295 PD1-PDL1 drug Opdivo nivolumab J9299 Spinal muscular atrophy Spinraza nusinersen J2326 Antineoplastic agent Gazyva obinutuzumab J9301 Multiple sclerosis drug Ocrevus ocrelizumab J2350 Somatostatin Analog Sandostatin LAR octreotide acetate J2353 Antineoplastic agent Arzerra ofatumumab J9302 Antineoplastic agent Lartruvo olaratumab J9285 Respiratory injectable Xolair omalizumab J2357 Botulinum toxins Botox onabotulinumtoxin A J0585 Spinal muscular atrophy Zolgensma onasemnogene abeparvovec-xioi J3399 Antineoplastic Abraxane paclitaxel protein-bound J9264 Antineoplastic agent Vectibix panitumumab J9303 Polyneuropathy drug Onpattro patisiran J0222 Ophthalmic injectable Macugen pegaptanib J2503 Granulocyte-colony stimulating factor Ziextenzo pegfilgrastim-bmez C9058/Q5120 Granulocyte-colony stimulating factor Udenyca pegfilgrastim-cbvq Q5111 Granulocyte-colony stimulating factor Fulphila pegfilgrastim-jmdb Q5108 Granulocyte-colony stimulating factor Neulasta pegfilgrastim-jmdb J2505 Gout medication Krystexxa pegloticase J2507 Antineoplastic agent Alimta pemetrexed J9305 PD1-PDL1 drug Keytruda pemobrolizumab J9271 HER-2 receptor drug Perjeta pertuzumab J9306 Antineoplastic agent Polivy polatuzumab vedotin-piiq J9309 Radiopharmaceutical Xofigo radium Pa 223 dichloride A9606 Antineoplastic Cyramza ramucirumab J9308 Ophthalmic injectable Lucentis ranibizumab J2778 Complement Inhibitor, monoclonal antibody Ultomiris ravulizumab-cwvz J1303 Erythropoiesis stimulating agent Retacrit recombinant human erythropoietin Q5106 Respiratory injectable Cinqair reslizumab J2786 Botulinum toxins Myobloc rimabotulinumtoxin B J0587 Immunologic agent Rituxan rituximab J9312 Immunologic agent Rituxan Hycela rituximab and hyaluronidase human J9311 Immunologic agent Truxima rituximab-abbs Q5115 Immunologic agent Ruxience rituximab-pvvr Q5119 Granulocyte-colony stimulating factor Nplate romiplostim J2796 Antineoplastic agent Trodelvy sacituzumab govitecan-hziy J9999 (non-specific) Immunoglobulin Cuvitru SC immune globulin J1555 Enzyme replacement drug Kanuma sebelipase alfa J2840 Cellular immunotherapy Provenge sipuleucel-T Q2043 Hyaluronic Acid agents Euflexxa sodium hyaluronate J7323 Hyaluronic Acid agents Gelsyn-3 sodium hyaluronate J7328 Hyaluronic Acid agents GenVisc 850 sodium hyaluronate J7320 Hyaluronic Acid agents Hyalgan sodium hyaluronate J7321 Hyaluronic Acid agents Supartz sodium hyaluronate J7321 Hyaluronic Acid agents Visco-3 sodium hyaluronate J7333 Enzyme replacement drug Elelyso taliglucerase alfa J3060 Ophthalmic injectable Tepezza teprotumumab-trbw J3241 CAR-T Therapy Kymriah tisagenlecleucel inpatient admin Immunologic agent Actemra, IV infusion tocilizumab J3262 Antineoplastic agent Yondelis trabectedin J9352 HER-2 receptor drug Herceptin trastuzumab J9355 HER-2 receptor drug Herceptin Hylecta trastuzumab and hyaluronidase-oysk J9356 HER-2 receptor drug Kanjinti trastuzumab-anns Q5117 HER-2 receptor drug Ogivri trastuzumab-dkst Q5114 HER-2 receptor drug Ontruzant trastuzumab-dttb Q5112 HER-2 receptor drug Herzuma trastuzumab-pkrb Q5113 HER-2 receptor drug Trazimera trastuzumab-qyyp Q5116 Pulmonary artierial hypertension drug Tyvaso, SubQ or IV infusion treprostinil J7686 Gonadtropin-releasing hormone agonist Trelstar triptorelin J3315 Immunologic agent Stelara, IV infusion ustekinumab J3358 Immunologic agent Entyvio vedolizumab J3380 Enzyme replacement drug Vpriv velaglucerase alfa J3385 Enzyme replacement drug Mepsevii vestronidase alfa-vjbk J3397 Ophthalmic injectable Luxturna voretigene neparvovex-rzyl J3398 Antineoplastic agent Zaltrap ziv-afilbercept J9400 Osteoporosis drug Reclast zoledronic acid J3489 Osteoporosis drug Zometa zoledronic acid J3489
Updated 4.1.2021