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Drug Code List Blue Cross Blue Shield Arizonia Specialty Drug Code List HCPCS Generic Name Product Name Therapeutic Category Code 90281 Immune Globulin Gamastan Immune deficiency 90283 Immune Globulin Gammagard Immune deficiency 90284 Immune Globulin Cuvitru Immune deficiency 90378 Palivizumab Synagis RSV Polyneuropathy of hereditary transthyretin-mediated C9036 Patisiran Onpattro amyloidosis in adults. C9257 Bevacizumab Avastin Ophthalmic disorder C9399 Defibrotide Defitelio Other C9399 Elapegademase-lvlr Revcovi ADA-SCID (PKU) with uncontrolled blood phenylalanine C9399 Pegvaliase-pqpz Palynziq concentrations greater than 600 micromol/L on existing management C9399 Pasireotide Signifor Other C9399 Ravulizumab-cwvz Ultomiris PNH C9399 Unclassified drug or biological (new drug) Unclassified drug or biological (new drug) J0178 Aflibercept Eylea Ophthalmic disorder J0180 Agalsidase Beta Fabrazyme Lysosomal storage disorders J0202 Alemtuzumab Lemtrada Multiple sclerosis J0221 Alglucosidase Alfa Lumizyme Lysosomal storage disorders J0256 Alpha1-proteinase inhibitors Aralast NP, Prolastin-C, Zemaira Alpha-1 antitrypsin deficiency J0257 Alpha1-proteinase inhibitors Glassia Alpha-1 antitrypsin deficiency J0364 Apomorphine Apokyn Other J0517 Benralizumab Fasenra Severe Asthma with an Eosinophilic phenotye J0565 Bezlotoxumab Zinplava C-Diff J0584 Burosumab-twza Crysvita X-linked hypophosphatemia (XLH) J0585 OnabotulinumtoxinA Botox Spacticity disorder Updated: 3/13/2019 V1.2019 Effective: 1/1/2019 HCPCS Generic Name Product Name Therapeutic Category Code J0586 AbobotulinumtoxinA Dysport Spacticity disorder J0587 RimabotulinumtoxinB Myobloc Spacticity disorder J0588 IncobotulinumtoxinA Xeomin Spacticity disorder J0596 C1 Esterase Inhibitor Ruconest Hereditary angioedema J0597 C1 Esterase Inhibitor Berinert Hereditary angioedema J0598 C1 Esterase Inhibitor Cinryze Hereditary angioedema Secondary Hyperthyroidism w/ Chronic Kidney disease J0606 Etelcalcetide Injection Parsabiv on Dialysis J0638 Canakinumab Ilaris CAPS J0775 Collagenase Clostridium Histolyticum Xiaflex Other J0881 Darbepoetin Alfa Aranesp, Aranesp for NON-ESRD Anemia J0885 Epoetin Alfa Epogen, Procrit Anemia J0888 Methoxy Polyethylene Glycol-Epoetin Beta Mircera, Mircera for NON-ESRD Anemia J0897 Denosumab Prolia Osteoporosis, bone mets, etc. J1300 Eculizumab Soliris PNH J1301 Edaravone Radicava Amyotropic lateral sclerosis (ALS) J1322 Elosulfase Alfa Vimizim Lysosomal storage disorders J1325 Epoprostenol Epoprostenol, Flolan, Veletri Pulmonary arterial hypertension J1428 Eteplirsen Exondys 51 Other J1439 Ferric Carboxymaltose Injectafer Anemia J1442 Filgrastim Neupogen Febrile neutropenia J1447 Tbo-filgrastim Granix Febrile neutropenia J1458 Galsulfase Naglazyme Lysosomal storage disorders J1459 Immune Globulin Privigen Immune deficiency J1460 Immune Globulin Gamastan Immune deficiency J1555 Immune Globulin Cuvitru Immune deficiency J1556 Immune Globulin Bivigam Immune deficiency J1557 Immune Globulin Gammaplex Immune deficiency J1559 Immune Globulin Hizentra Immune deficiency J1560 Immune Globulin Gamastan Immune deficiency J1561 Immune Globulin Gamunex-C, Gammaked Immune deficiency Carimune NF, Gammagard S/D, J1566 Immune Globulin Immune deficiency Panglobulin NF Updated: 3/13/2019 V1.2019 Effective: 1/1/2019 HCPCS Generic Name Product Name Therapeutic Category Code J1568 Immune Globulin Octagam Immune deficiency J1569 Immune Globulin Gammagard liquid Immune deficiency J1572 Immune Globulin Flebogamma DIF Immune deficiency J1575 Immune Globulin Hyqvia Immune deficiency J1602 Golimumab Simponi Aria Immunomodulators J1740 Ibandronate sodium Boniva Osteoporosis J1743 Idursulfase Elaprase Lysosomal storage disorders J1745 Infliximab Remicade Immunomodulators J1746 Ibalizumab-uryk Trogarzo HIV J1786 Imiglucerase Cerezyme Lysosomal storage disorders J1930 Lanreotide Somatuline Growth disorder J1931 Laronidase Aldurazyme Lysosomal storage disorders J2182 Mepolizumab Nucala Asthma J2323 Natalizumab Tysabri Multiple sclerosis J2326 Nusinersen Spinraza Spinal muscular atrophy J2350 Ocrelizumab Ocrevus Multiple sclerosis J2353 Octreotide Sandostatin Depot Growth disorder J2354 Octreotide Sandostatin Growth disorder J2357 Omalizumab Xolair Asthma J2502 Pasireotide Signifor LAR Other J2503 Pegaptanib Sodium Macugen Ophthalmic disorder J2504 - drug being retired Pegademase Bovine Adagen Lysosomal storage disorders 4/1/19 J2507 Pegloticase Krystexxa Gout J2778 Ranibizumab Lucentis Ophthalmic disorder J2786 Reslizumab Cinqair Asthma J2793 Rilonacept Arcalyst CAPS J2796 Romiplostim Nplate ITP J2820 Sargramostim Leukine Febrile neutropenia J2840 Sebelipase alfa Kanuma Lysosomal Acid Lipase (LAL) deficiency J3060 Taliglucerase Alfa Elelyso Lysosomal storage disorders J3245 Tildrakizumab-asmn Ilumya Plaque psoriasis Updated: 3/13/2019 V1.2019 Effective: 1/1/2019 HCPCS Generic Name Product Name Therapeutic Category Code J3285 Treprostinil Remodulin Pulmonary arterial hypertension J3304 Triamcinolone ER Zilretta Osteoarthritis pain (knee) J3316 Triptorelin ER Triptodur Central Precocious Puberty J3380 Vedolizumab Entyvio Immunomodulators J3385 Velaglucerase Alfa Vpriv Lysosomal storage disorders J3396 Verteporfin Visudyne Ophthalmic disorder J3397 Vestronidase alfa-vjbk Mepsevii Mucopolysaccharidosis VII (MPS VII, Sly syndrome) J3489 Zoledronic Acid Reclast Osteoporosis, bone mets, etc. J3490 Intra-Articular Hyaluronan Injections Synojoynt Osteoarthritis J3490 Defibrotide Defitelio Other J3490 Sildenafil Revatio Pulmonary arterial hypertension J3490 Pasireotide Signifor Other J3490 Unclassified (new drug) Unclassified (new drug) J3590 Elapegademase-lvlr Revcovi ADA-SCID J3590 Intra-Articular Hyaluronan Injections Synojoynt Osteoarthritis (PKU) with uncontrolled blood phenylalanine J3590 pegvaliase-pqpz Palynziq concentrations greater than 600 micromol/L on existing management J3590 Ravulizumab-cwvz Ultomiris PNH J3590 Unclassified Biologic (new drug) Unclassified Biologic (new drug) J7170 Emicizumab-kxwh Hemlibra Hemophilia factor and other bleeding disorders J7175 Coagulation Factor X (Human) Coagadex Hemophilia factor and other bleeding disorders J7177 Human fibrinogen concentrate Fibryga Hemophilia factor and other bleeding disorders J7178 Fibrinogen (Human) RiaSTAP Hemophilia factor and other bleeding disorders J7179 von Willebrand Factor (Recombinant) Vonvendi Hemophilia factor and other bleeding disorders Factor XIII Concentrate (antihemophilic factor, J7180 Corifact Hemophilia factor and other bleeding disorders human) J7181 Coagulation Factor XIII A-Subunit (Recombinant) Tretten Hemophilia factor and other bleeding disorders J7182 Factor VIII (antihemophilic Factor,Recombinant) Novoeight Hemophilia factor and other bleeding disorders J7183 von Willebrand Factor complex (human) Wilate Hemophilia factor and other bleeding disorders J7185 Factor VIII (antihemophilic Factor,Recombinant) Xyntha Hemophilia factor and other bleeding disorders Updated: 3/13/2019 V1.2019 Effective: 1/1/2019 HCPCS Generic Name Product Name Therapeutic Category Code J7186 von Willebrand Factor complex (human) Alphanate Hemophilia factor and other bleeding disorders J7187 von Willebrand Factor complex Humate-P Hemophilia factor and other bleeding disorders J7188 Antihemophilic Factor (Recombinant) Obizur Hemophilia factor and other bleeding disorders J7189 Factore VIIA (antihemophilic factor, recombinant) NovoSeven-RT Hemophilia factor and other bleeding disorders J7190 Factor VIII (antihemophilic factor, human) Koate/Koate-DVI, Hemofil M, Monoclate-P Hemophilia factor and other bleeding disorders Advate, Kogenate FS, Recombinate, J7192 Factor VIII (antihemophilic Factor,Recombinant) Hemophilia factor and other bleeding disorders Helixate FS Factor IX (antihemophilic factor, purified, non- J7193 AlphaNine SD, Mononine Hemophilia factor and other bleeding disorders recombinant) J7194 Factor IX Complex Bebulin, Profilnine/Profilnine SD Hemophilia factor and other bleeding disorders J7195 Factor IX (antihemophilic factor, recombinant) BeneFix, Ixinity Hemophilia factor and other bleeding disorders J7198 Anti-inhibitor Feiba Hemophilia factor and other bleeding disorders Hemophilia clotting factor, not otherwise J7199 Hemophilia clotting factor, not otherwise classified Hemophilia factor and other bleeding disorders classified J7200 Factor IX (antihemophilic factor, recombinant) Rixubis Hemophilia factor and other bleeding disorders J7201 Factor IX (Fc fusion protein, recombinant) Alprolix Hemophilia factor and other bleeding disorders J7202 Factor IX (albumin fusion protein, recombinant) Idelvion Hemophilia factor and other bleeding disorders Factor IX (antihemophilic factor, recombinant), J7203 Rebinyn Hemophilia factor and other bleeding disorders glycopegylated J7205 Factor VIII (Fc fusion protein, recombinant) Eloctate Hemophilia factor and other bleeding disorders Factor VIII (antihemophilic factor, recombinant), J7207 Adynovate Hemophilia factor and other bleeding disorders pegylated J7209 Factor VIII (antihemophilic factor, recombinant) Nuwiq Hemophilia factor and other bleeding disorders J7210 Factor VIII (antihemophilic factor, recombinant) Afstyla Hemophilia factor and other bleeding disorders J7211 Factor VIII (antihemophilic factor, recombinant) Kovaltry Hemophilia factor and other bleeding disorders J7311 Fluocinolone Acetonide Intravitreal Implant Retisert Ophthalmic disorder J7312 Dexamethasone Intravitreal Implant Ozurdex Ophthalmic disorder J7313 Fluocinolone Acetonide Intravitreal Implant Iluvien Ophthalmic
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