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DRUGS REQUIRING PRIOR AUTHORIZATION in the MEDICAL BENEFIT Page 1 Effective Date: 08/01/2021 DRUGS REQUIRING PRIOR AUTHORIZATION IN THE MEDICAL BENEFIT Page 1 Therapeutic Category Drug Class Trade Name Generic Name HCPCS Procedure Code HCPCS Procedure Code Description Anti-infectives Antiretrovirals, HIV CABENUVA cabotegravir-rilpivirine C9077 Injection, cabotegravir and rilpivirine, 2mg/3mg Antithrombotic Agents von Willebrand Factor-Directed Antibody CABLIVI caplacizumab-yhdp C9047 Injection, caplacizumab-yhdp, 1 mg Cardiology Antilipemic EVKEEZA evinacumab-dgnb C9079 Injection, evinacumab-dgnb, 5 mg Cardiology Hemostatic Agent BERINERT c1 esterase J0597 Injection, C1 esterase inhibitor (human), Berinert, 10 units Cardiology Hemostatic Agent CINRYZE c1 esterase J0598 Injection, C1 esterase inhibitor (human), Cinryze, 10 units Cardiology Hemostatic Agent FIRAZYR icatibant J1744 Injection, icatibant, 1 mg Cardiology Hemostatic Agent HAEGARDA c1 esterase J0599 Injection, C1 esterase inhibitor (human), (Haegarda), 10 units Cardiology Hemostatic Agent ICATIBANT (generic) icatibant J1744 Injection, icatibant, 1 mg Cardiology Hemostatic Agent KALBITOR ecallantide J1290 Injection, ecallantide, 1 mg Cardiology Hemostatic Agent RUCONEST c1 esterase J0596 Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 units Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under Cardiology Hemostatic Agent TAKHZYRO lanadelumab-flyo J0593 direct supervision of a physician, not for use when drug is self-administered) Cardiology Pulmonary Arterial Hypertension EPOPROSTENOL (generic) epoprostenol J1325 Injection, epoprostenol, 0.5 mg Cardiology Pulmonary Arterial Hypertension FLOLAN epoprostenol J1325 Injection, epoprostenol, 0.5 mg Cardiology Pulmonary Arterial Hypertension REMODULIN treprostinil J3285 Injection, treprostinil, 1 mg Cardiology Pulmonary Arterial Hypertension TREPROSTINIL (generic) treprostinil J3285 Injection, treprostinil, 1 mg Cardiology Pulmonary Arterial Hypertension VELETRI epoprostenol J1325 Injection, epoprostenol, 0.5 mg Central Nervous System Antidepressants SPRAVATO esketamine S0013 Esketamine, nasal spray, 1 mg Central Nervous System Antidepressants ZULRESSO brexanolone J1632 Injection, brexanolone, 1 mg Central Nervous System Antipsychotics ABILIFY MAINTENA aripiprazole ER J0401 Injection, aripiprazole, extended release, 1 mg Central Nervous System Migraine AIMOVIG erenumab-aooe J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered Central Nervous System Migraine AJOVY fremanezumab-vfrm J3031 under the direct supervision of a physician, not for use when drug is self-administered) Central Nervous System Migraine EMGALITY galcanezumab-gnlm J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Central Nervous System Migraine VYEPTI eptinezumab-jjmr iv J3032 Injection, eptinezumab-jjmr, 1 mg Central Nervous System Miscellaneous RADICAVA edaravone J1301 Injection, edaravone, 1 mg Central Nervous System Muscular Dystrophy EXONDYS 51 eteplirsen J1428 Injection, eteplirsen, 10 mg Central Nervous System Muscular Dystrophy VILTEPSO viltolarsen J1427 Injection, viltolarsen, 10 mg Central Nervous System Muscular Dystrophy VYONDYS 53 golodirsen J1429 Injection, golodirsen, 10 mg Central Nervous System Neurological Agents ONPATTRO patisiran sodium J0222 Injection, patisiran, 0.1 mg Central Nervous System Neurological Agents TEGSEDI inotersen J3490/C9399 (Hospital Outpt Use Only) Unclassified drugs/Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Central Nervous System Neurotoxins BOTOX onabotulinumtoxinA J0585 Injection, onabotulinumtoxinA, 1 unit Central Nervous System Neurotoxins BOTOX COSMETIC onabotulinumtoxinA J0585 Injection, onabotulinumtoxinA, 1 unit Central Nervous System Neurotoxins DYSPORT abobotulinumtoxinA J0586 Injection, abobotulinumtoxinA, 5 units Central Nervous System Neurotoxins MYOBLOC rimabotulinumtoxinB J0587 Injection, rimabotulinumtoxinB, 100 units Central Nervous System Neurotoxins XEOMIN incobotulinumtoxinA J0588 Injection, incobotulinumtoxinA, 1 unit Central Nervous System Parkinson's APOKYN apomorphine J0364 Injection, apomorphine HCl, 1 mg Endocrinology & Metabolism Gonadotropins ELIGARD leuprolide J9217 Leuprolide acetate (for depot suspension), 7.5 mg Endocrinology & Metabolism Gonadotropins FENSOLVI leuprolide acet J1951 Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg Endocrinology & Metabolism Gonadotropins FIRMAGON degarelix J9155 Injection, degarelix, 1 mg Endocrinology & Metabolism Gonadotropins LEUPROLIDE (generic) leuprolide J9218 Leuprolide acetate, per 1 mg Endocrinology & Metabolism Gonadotropins LUPANETA PACK leuprolide J3490/C9399 (Hospital Outpt Use Only) Unclassified drugs/Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Endocrinology & Metabolism Gonadotropins LUPRON DEPOT leuprolide J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg LUPRON DEPOT leuprolide J9217 Leuprolide acetate (for depot suspension), 7.5 mg Endocrinology & Metabolism Gonadotropins LUPRON DEPOT-PED leuprolide J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg LUPRON DEPOT-PED leuprolide J9217 Leuprolide acetate (for depot suspension), 7.5 mg Endocrinology & Metabolism Gonadotropins SUPPRELIN LA histrelin acetate J9226 Histrelin implant (Supprelin LA), 50 mg Endocrinology & Metabolism Gonadotropins TRELSTAR triptorelin J3315 Injection, triptorelin pamoate, 3.75 mg Endocrinology & Metabolism Gonadotropins TRIPTODUR triptorelin J3316 Injection, triptorelin, extended-release, 3.75 mg Endocrinology & Metabolism Gonadotropins VANTAS histrelin J9225 Histrelin implant (Vantas), 50 mg Endocrinology & Metabolism Growth Hormones and Related Therapy GENOTROPIN somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy HUMATROPE somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy NORDITROPIN FLEXPRO somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy NUTROPIN AQ somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy OMNITROPE somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy SAIZEN somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy SEROSTIM somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy ZOMACTON somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy ZORBTIVE somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Miscellaneous ACTHAR corticotropin J0800 Injection, corticotropin, up to 40 units Endocrinology & Metabolism Monoclonal Antibody TEPEZZA teprotumumab-trbw J3241 Injection, teprotumumab-trbw, 10 mg Endocrinology & Metabolism Osteoporosis EVENITY romosozumab-aqqg J3111 Injection, romosozumab-aqqg, 1 mg Endocrinology & Metabolism Osteoporosis FORTEO teriparatide J3110 Injection, teriparatide, 10 mcg Endocrinology & Metabolism Osteoporosis PROLIA denosumab J0897 Injection, denosumab, 1 mg Endocrinology & Metabolism Osteoporosis TERIPARATIDE (Brand) teriparatide (recombinant) J3110 Injection, teriparatide, 10 mcg Endocrinology & Metabolism Osteoporosis TYMLOS abaloparatide J3490/C9399 (Hospital Outpt Use Only) Unclassified drugs/Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Endocrinology & Metabolism Somatostatins BYNFEZIA octreotide acetate J2354 Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg Endocrinology & Metabolism Somatostatins OCTREOTIDE (generic) octreotide J2354 Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg Endocrinology & Metabolism Somatostatins SANDOSTATIN octreotide J2354 Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg Endocrinology & Metabolism Somatostatins SANDOSTATIN LAR octreotide J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg Endocrinology & Metabolism Somatostatins SIGNIFOR LAR pasireotide J2502 Injection, pasireotide long acting, 1 mg Endocrinology & Metabolism Somatostatins SOMATULINE DEPOT lanreotide J1930 Injection, lanreotide, 1 mg Enzyme-Related Alpha-1 proteinase inhibitor ARALAST NP alpha-1 proteinase inhibitor J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg Enzyme-Related Alpha-1 proteinase inhibitor GLASSIA alpha-1 proteinase inhibitor J0257 Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg Enzyme-Related Alpha-1 proteinase inhibitor PROLASTIN-C alpha-1 proteinase inhibitor J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg Enzyme-Related Alpha-1 proteinase inhibitor ZEMAIRA alpha-1 proteinase inhibitor J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg Enzyme-Related Enzyme Replacement CEREZYME imiglucerase J1786 Injection, imiglucerase, 10 units Enzyme-Related Enzyme Replacement ELELYSO taliglucerase J3060 Injection, taliglucerase alfa, 10 units Revised: 07/28/2021 Effective Date: 08/01/2021 DRUGS REQUIRING PRIOR AUTHORIZATION IN THE MEDICAL BENEFIT
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