BIOPHARMACEUTICAL PHARMACY PROGRAM
bsolute Total Care provides a number of biopharmaceutical products through the Biopharmaceutical Pharmacy Program. The program helps deliver medications to members or A provider offices that are not traditionally found at a local pharmacy. Most biopharmaceuticals and injectables billed for more than $250 require a prior authorization (PA) to be approved for payment by Absolute Total Care; however, PA requirements are programmed specific to the drug as indicated in the table below. Since the list of drugs requiring PA changes over time, due to new drug arrivals and other market conditions, the $250 amount is used as a reference gauge to help in determining whether to apply for PA. Some of these products can be delivered to the member or directly to the provider’s location for office administration through Acaria Health. Prescribers can submit requests for biopharmaceutical products to Absolute Total Care by filling out the Absolute Total Care Specialty Medications Prior Authorization Form that is available on the Coordinated Care website at www.absolutetotalcare.com. Fax the Absolute Total Care Specialty Medications Prior Authorization Form to 1-855-865-9469 or call Absolute Total Care at 1-866-433-6041 ext. 64455. If approved, Acaria Health Specialty Pharmacy will contact the member and/or the provider for delivery confirmation.
Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL 90281 GLOBULIN, IMMUNE providers Auth required for all GENERAL 90283 GLOBULIN, IMMUNE providers GLOBULIN, IMMUNE SC Auth required for all GENERAL 90284 (ZLB BEHRING) providers GLOBULIN, IMMUNE SC Auth required for all GENERAL 90291 (ZLB BEHRING) providers Auth required for all GENERAL 90378 Synagis PALIVIZUMAB providers Auth required for all providers except HEM/ONC A9542 Zevalin IBRITUMOMAB TIUXETAN hospital, hematology, or oncology providers. Auth required for all providers except IODINE I 131 HEM/ONC A9545 Bexxar hospital, TOSITUMOMAB hematology, or oncology providers.
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Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all HEM/ONC J9035 Avastin BEVACIZUMAB providers Auth required for all GENERAL J0485 Nulojix BELATACEPT providers Auth required for all providers except HEM/ONC J9042 Adcetris BRENTUXIMAB VEDOTIN hospital, hematology, or oncology providers. Auth required for all MISC C9399 MISC MISC CODES providers Auth required for all providers except HEM/ONC G3001 Bexxar TOSITUMOMAB hospital, hematology, or oncology providers. Auth required for all GENERAL J0129 Orencia ABATACEPT providers Auth required for all GENERAL J0135 Humira ADALIMUMAB providers Auth required for all GENERAL J0180 Fabrazyme AGALSIDASE BETA providers Auth required for all GENERAL J0205 Ceredase ALGLUCERASE providers Auth required for all GENERAL J0207 Ethyol AMIFOSTINE providers Auth required for all GENERAL J0215 Amevive ALEFACEPT providers Auth required for all GENERAL J0220 Myozyme ALGLUCOSIDASE ALFA providers Auth required for all GENERAL J0221 Lumizyme ALGLUCOSIDASE ALFA providers Prolastin; PROTEINASE INHIBITOR Auth required for all GENERAL J0256 Zemira (HUMAN) providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information
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ALPHA 1 PROTEINASE Auth required for all GENERAL J0257 Glassia INHIBITOR (HUMAN) providers APOMORPHINE Auth required for all GENERAL J0364 Apokyn HYDROCHLORIDE providers Auth required for all GENERAL J0480 Simulect BASILIXIMAB providers Auth required for all GENERAL J0490 Benlysta BELIMUMAB providers CLOSTRIDIUM Auth required for all GENERAL J0585 Botox BOTULINUM TOXIN TYPE providers A Auth required for all GENERAL J0586 Dysport ABOBOTULINUMTOXINA providers CLOSTRIDIUM Auth required for all GENERAL J0587 Myobloc BOTULINUM TOXIN TYPE providers B INCOBOTULINUMTOXIN Auth required for all GENERAL J0588 Xeomin A providers Auth required for all providers except HEM/ONC J0594 Busulfex BUSULFAN hospital, hematology, or oncology providers. Auth required for all GENERAL J0597 Berinert C 1 ESTERASE, BERINERT providers Auth required for all GENERAL J0598 Cinryze C1 INHIBITOR (HUMAN) providers Auth required for all GENERAL J0638 Ilaris CANAKINUMAB providers LEVOLEUCOVORIN Auth required for all GENERAL J0641 Fusilev CALCIUM providers COLLAGENASE, CLOST Auth required for all GENERAL J0775 Xiaflex HIST providers Auth required for all GENERAL J0800 HP Acthar Gel CORTICOTROPIN providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information
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CYTOMEGALOVIRUS Auth required for all GENERAL J0850 CytoGam IMMUNE GLOBULIN providers Aranesp (non Auth required for all GENERAL J0881 DARBEPOETIN ALFA ESRD) providers Auth required for all GENERAL J0882 Aranesp (ESRD) DARBEPOETIN ALFA providers Epogen; Procrit Auth required for all GENERAL J0885 EPOETIN ALFA (non ESRD) providers Epogen; Procrit Auth required for all GENERAL J0886 EPOETIN ALFA (ESRD) providers Auth required for all providers except HEM/ONC J0894 Dacogen DECITABINE hospital, hematology, or oncology providers. DEFEROXAMINE Auth required for all GENERAL J0895 Desferal MESYLATE providers Auth required for all GENERAL J0897 Prolia; Xgeva DENOSUMAB INJECTION providers Auth required for all GENERAL J1190 Zinecard DEXRAZOXANE providers Auth required for all GENERAL J1290 Kalbitor ECALLANTIDE providers Auth required for all GENERAL J1300 Soliris ECULIZUMAB providers Auth required for all GENERAL J1324 Fuzeon ENFUVIRTIDE providers Auth required for all GENERAL J1325 Flolan EPOPROSTENOL SODIUM providers Auth required for all GENERAL J1438 Enbrel ETANERCEPT providers Neupogen Auth required for all GENERAL J1442 300mcg & FILGRASTIM providers 480mcg Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL J1458 Naglazyme GALSULFASE providers
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GLOBULIN, IMMUNE IV Auth required for all GENERAL J1459 Privigen (BAXTER/AM RED CROS) providers Auth required for all GENERAL J1460 GamaSTAN S/D GLOBULIN, IMMUNE providers Auth required for all GENERAL J1557 Gammaplex GLOBULIN, IMMUNE providers Auth required for all GENERAL J1559 Hizentra HIZENTRA providers Auth required for all GENERAL J1560 GamaSTAN S/D GLOBULIN, IMMUNE providers GLOBULIN, IMMUNE IV Auth required for all GENERAL J1561 Gamunex (TALECRIS) providers GLOBULIN, IMMUNE SC Auth required for all GENERAL J1562 Vivaglobin (ZLB BEHRING) providers Auth required for all GENERAL J1566 Carimune GLOBULIN, IMMUNE providers GLOBULIN, IMMUNE IV Auth required for all GENERAL J1568 Octagam (OCTAPHARM) providers Gammagard GLOBULIN, IMMUNE IV Auth required for all GENERAL J1569 Liquid (BAXTER/AM RED CROS) providers Auth required for all GENERAL J1572 Febogamma GLOBULIN, IMMUNE providers Auth required for all GENERAL J1595 Copaxone GLATIRAMER ACETATE providers IVIG NON LYOPHILIZED, Auth required for all MISC J1599 MISC NOS providers Auth required for all GENERAL J1640 Panhematin HEMIN providers Auth required for all GENERAL J1645 Fragmin DALTEPARIN SODIUM providers Auth required for all GENERAL J1650 Lovenox ENOXAPARIN SODIUM providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL J1652 Arixtra FONDAPARINUX SODIUM providers Auth required for all GENERAL J1655 Innohep TINZAPARIN SODIUM providers
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FIBRINOGEN Auth required for all GENERAL J7178 RiaSTAP CONCENTRATE (HUMAN) providers
HYDROXYPROGESTERONE Auth required for all GENERAL J1725 Makena CAPROATE providers Auth required for all GENERAL J1740 Boniva IBANDRONATE SODIUM providers Auth required for all GENERAL J1743 Elaprase IDURSULFASE providers Auth required for all GENERAL J1745 Remicade INFLIXIMAB providers Auth required for all GENERAL J1786 Cerezyme IMUGLUCERASE providers Auth required for all GENERAL J1826 Avonex INTERFERON BETA 1A providers Auth required for all GENERAL J1830 Betaseron INTERFERON BETA 1B providers Auth required for all GENERAL J1930 Somatuline LANREOTIDE ACETATE providers Auth required for all GENERAL J1931 Aldurazyme LARONIDASE providers Eliguard; Lupron; Lupron Auth required for all GENERAL J1950 LEUPROLIDE ACETATE 3; Lupron 4; providers Lupron Depot Auth required for all GENERAL J2170 Iplex; Increlex MECASERMIN providers Auth required for all GENERAL J2278 Prialt ZICONOTIDE ACETATE providers Auth required for all GENERAL J2315 Vivitrol NALTREXONE providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL J2323 Tysabri NATALIZUMAB providers Auth required for all GENERAL J2325 Natrecor NESIRITIDE providers
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Sandostatin Auth required for all GENERAL J2353 OCTREOTIDE ACETATE LAR providers Auth required for all GENERAL J2354 Sandostatin OCTREOTIDE ACETATE providers Auth required for all GENERAL J2355 Neumega OPRELVEKIN providers Auth required for all GENERAL J2357 Xolair OMALIZUMAB providers Zyprexa OLANZAPINE LONG Auth required for all GENERAL J2358 Relprevv ACTING providers Auth required for all GENERAL J2425 Keprivance PALIFERMIN providers Invega PALIPERIDONE Auth required for all GENERAL J2426 Sustenna PALMITATE providers PEGAPTANIB SODIUM Auth required for all GENERAL J2503 Macugen (PEGAPTANIB providers OCTASODIUM Auth required for all GENERAL J2504 Adagen PEGADEMASE BOVINE providers Auth required for all GENERAL J2505 Neulasta PEGFILGRASTIM providers Auth required for all GENERAL J2507 Krystexxa PEGLOTICASE providers Auth required for all GENERAL J2562 Mozobil PLERIXAFOR providers Auth required for all GENERAL J2724 Ceprotin HUMAN PROTEIN C providers Auth required for all GENERAL J2778 Lucentis RANIBIZUMAB providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL J2783 Elitek RASBURICASE providers RHO (D) IMMUNE Auth required for all GENERAL J2791 HypRho SD GLOBULIN providers RHO (D) IMMUNE Auth required for all GENERAL J2792 WINRho SDF GLOBULIN providers
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Auth required for all GENERAL J2793 Arcalyst RILONACEPT providers Risperdal Auth required for all GENERAL J2794 RISPERIDONE Consta providers Auth required for all GENERAL J2796 Nplate ROMIPLOSTIM providers Auth required for all GENERAL J2820 Leukine SARGRAMOSTIM providers Humatrope; Genotropin Nutropin; Biotropin; Genotropin; Genotropin Miniquick; Norditropin; Nutropin; Auth required for all GENERAL J2941 SOMATROPIN Nutropin AQ; providers Saizen; Saizen Somatropin RDNA; Serostim, Serostim RFNA; Zorbtive; Tev- Tropin (preferred) Auth required for all GENERAL J3095 Vibativ TELEVANCIN providers Auth required for all GENERAL J3110 Forteo TERIPARATIDE providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL J3240 Thyrogen THYROTROPIN ALFA providers Auth required for all GENERAL J3262 Actemra TOCILIZUMAB providers Auth required for all GENERAL J3285 Remodulin TREPROSTINIL SODIUM providers
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Trelstar Depot; Trelstar Depot Auth required for all GENERAL J3315 TRIPTORELIN PAMOATE Plus; Debioclip providers Kit; Trelstar LA Auth required for all GENERAL J3357 Stelara USTEKINUMAB providers Auth required for all GENERAL J3385 Vpriv VELAGLUCERASE ALFA providers Auth required for all GENERAL J3396 Visudyne VERTEPORFIN providers Zometa; Auth required for all GENERAL J3489 ZOLEDRONIC ACID Reclast providers Auth required for all MISC J3490 MISC MISC CODES providers Auth required for all MISC J3590 MISC MISC CODES providers FACTOR XIII ANTI HEM Auth required for all HEMOPHILIA J7180 Corifact FACTOR providers Auth required for all HEMOPHILIA J7183 Wilate WILATE INJECTION providers ANTIHEMOPHILIC Auth required for all HEMOPHILIA J7185 Xyntha FACTOR (RECOMB) PAF providers ANTIHEMOPHILIC Auth required for all HEMOPHILIA J7186 Alphanate FACTOR/VWF CMPLX providers (HUMAN) ANTIHEMOPHILIC Auth required for all HEMOPHILIA J7187 Humate P FACTOR/VWF CMPLX providers (HUMAN) Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information FACTOR VIIA Auth required for all HEMOPHILIA J7189 NovoSeven RT COAGULANT, providers RECOMB(BHK CELLS) Koate DVI; ANTIHEMOPHILIC Auth required for all HEMOPHILIA J7190 Monarc M; FACTOR providers Monoclate P
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Recombinate; Kogenate FS; Hexlixate FX; Advate rAHF PFM; ANTIHEMOPHILIC Auth required for all HEMOPHILIA J7192 Antihemophilic FACTOR RAHF PFM providers Factor Human Method M Monoclonal Purified; Refacto AlphaNine SD ; COAGULATION FACTOR Auth required for all HEMOPHILIA J7193 Mononine IX providers Konyne 80; Profilnine SD; Proplex T; Auth required for all HEMOPHILIA J7194 FACTOR IX Bebulin VH; providers factor IX+ complex COAGULATION FACTOR Auth required for all HEMOPHILIA J7195 Benefix IX, RECOMBINANT providers ANTITHROMBIN Auth required for all GENERAL J7196 Atryn RECOMBINANT providers Thrombate III; Antithrombin III (human), Auth required for all HEMOPHILIA J7197 Atnativ per IU providers Autoplex T; ANTI INHIBITOR Auth required for all HEMOPHILIA J7198 Feiba VH AICC COAGULANT COMPLEX providers Hemophilia clotting Auth required for all HEMOPHILIA J7199 MISC factor, not otherwise providers classified Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL J7310 Vitrasert GANCICLOVIR providers DEXAMETHASONE INTRA Auth required for all GENERAL J7312 Ozurdex IMPLANT providers Hyalgan; Auth required for all GENERAL J7321 SODIUM HYALURONATE Supartz providers Auth required for all GENERAL J7323 Euflexxa SODIUM HYALURONATE providers
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Auth required for all GENERAL J7324 Orthovisc HYALURONAN providers Synvisc; Synvisc Auth required for all GENERAL J7325 HYLAN One providers CROSS-LINKED Auth required for all GENERAL J7326 Gel One HYALURONATE GEL providers ANTI THYMOCYTE Auth required for all GENERAL J7504 Atgam GLOBULIN (EQUINE) providers ANTI THYMOCYTE Auth required for all GENERAL J7511 Thymoglobulin GLOBULIN (RABBIT) providers Auth required for all GENERAL J7513 Zenapax DACLIZUMAB providers Neoral; Sandimmune; Auth required for all GENERAL J7516 CYCLOSPORINE Gengraf; providers Sangcya MYCOPHENOLATE Auth required for all GENERAL J7517 Cellcept MOFETIL providers MYCOPHENOLATE Auth required for all GENERAL J7518 Myfortic SODIUM providers Auth required for all GENERAL J7525 Prograf TACROLIMUS providers
Immunosuppressive drug, Auth required for all GENERAL J7599 MISC not otherwise classified providers
Auth required for all GENERAL J7639 Pulmozyme DORNASE ALFA providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all GENERAL J7682 Tobi TOBRAMYCIN providers Auth required for all GENERAL J7686 Tyvaso TREPROSTINIL providers Auth required for all MISC J8499 MISC MISC CODES providers Auth required for all GENERAL J8510 Myleran BUSULFAN providers
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CAPECITABINE, ORAL (per Auth required for all GENERAL J8520 Xeloda 150mg) providers CAPECITABINE, ORAL (per Auth required for all GENERAL J8521 Xeloda 500mg) providers Auth required for all GENERAL J8530 Cytoxan (Oral) CYCLOPHOSPHAMIDE providers Auth required for all GENERAL J7527 Zortress EVEROLIMUS providers FLUDARABINE Auth required for all GENERAL J8562 Oforta PHOSPHATE providers Auth required for all GENERAL J8565 Iressa GEFITINIB providers Auth required for all GENERAL J8600 Alkeran MELPHALAN providers TEMOZOLOMIDE (per Auth required for all GENERAL J8700 Temodar 5mg) providers TOPOTECAN Auth required for all GENERAL J8705 Hycamtin HYDROCHLORIDE providers
oral, chemotherapeutic, Auth required for all MISC J8999 MISC Not Otherwise Specified providers
Auth required for all Adriamycin providers except PFS; DOXORUBICIN HEM/ONC J9000 hospital, Adriamycin HYDROCHLORIDE hematology, or RDF; Rubex oncology providers. Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9010 Campath ALEMTUZUMAB hospital, hematology, or oncology providers. Auth required for all providers except Proleukin; IL 2; HEM/ONC J9015 ALDESLEUKIN hospital, Interleukin hematology, or oncology providers.
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Auth required for all providers except HEM/ONC J9017 Trisenox ARSENIC TRIOXIDE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9020 Elspar ASPARAGINASE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9025 Vidaza AZACITIDINE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9027 Clolar CLOFARABINE hospital, hematology, or oncology providers.
Auth required for all TheraCys, Tice providers except HEM/ONC J9031 BCG; PACIS BCG VACCINE hospital, BCG hematology, or oncology providers.
Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except BENDAMUSTINE HEM/ONC J9033 Treanda hospital, HYDROCHLORIDE hematology, or oncology providers. Auth required for all Avastin BEVACIZUMAB (per GENERAL C9257 providers except for (Intraocular) 0.25mg) OPHTHALMOLOGISTS Auth required for all providers except HEM/ONC J9040 Blenoxane BLEOMYCIN SULFATE hospital, hematology, or
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oncology providers.
Auth required for all providers except HEM/ONC J9041 Velcade BORTEZOMIB hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9043 Jevtana CABAZITAXEL hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9045 Paraplatin CARBOPLATIN hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9050 BiCNU CARMUSTINE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9055 Erbitux CETUXIMAB hospital, hematology, or oncology providers. Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9060 Plantinol AQ CISPLATIN hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9065 Leustatin CLADRIBINE hospital, hematology, or oncology providers.
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Auth required for all providers except Endoxan Asta/ hospital, HEM/ONC J9070 Cytoxan CYCLOPHOSPHAMIDE hematology, Injectable neurology, oncology or rheumatology providers. Auth required for all providers except HEM/ONC J9098 Depocyt CYTARABINE hospital, hematology, or oncology providers. Auth required for all providers except Cytosar U; Ara HEM/ONC J9100 CYTARABINE hospital, C; Tarabin CFS hematology, or oncology providers. Auth required for all providers except HEM/ONC J9120 Cosmegen DACTINOMYCIN hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9130 Dtic Dome DACARBAZINE hospital, hematology, or oncology providers. Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except DAUNORUBICIN HEM/ONC J9150 Cerubidine hospital, HYDROCHLORIDE hematology, or oncology providers. Auth required for all providers except HEM/ONC J9151 Daunoxone DAUNORUBICIN CITRATE hospital, hematology, or oncology providers. Auth required for all GENERAL J9155 Degarelix DEGARELIX ACETATE providers
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Auth required for all providers except HEM/ONC J9160 Ontak DENILEUKIN DIFTITOX hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9171 Taxotere DOCETAXEL hospital, hematology, or oncology providers. CALCIUM CHLORIDE DIHYDRATE; DEXTROSE (ANHYDROUS); Auth required for all MAGNESIUM SULFATE, providers except Elliott's B HEPTAHYDRATE; HEM/ONC J9175 hospital, Solution 1ml POTASSIUM CHLORIDE; hematology, or SODIUM BICARBONATE; oncology providers. SODIUM CHLORIDE; SODIUM PHOSPHATE, DIBASIC Auth required for all providers except HEM/ONC J9178 Ellence EPIRUBICIN HCL hospital, hematology, or oncology providers. Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9179 Halaven ERIBULIN MESYLATE hospital, hematology, or oncology providers. Auth required for all providers except VePesid; HEM/ONC J9181 ETOPOSIDE hospital, Toposar hematology, or oncology providers. Auth required for all FLUDARABINE providers except HEM/ONC J9185 Fludara PHOSPHATE hospital, hematology, or
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oncology providers.
Auth required for all providers except HEM/ONC J9190 Adrucil FLUOROURACIL hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9200 FUDR FLOXURIDINE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9201 Gemzar GEMCITABINE HCL hospital, hematology, or oncology providers. Auth required for all GENERAL J9202 Zoladex GOSERELIN ACETATE providers Auth required for all providers except IRINOTECAN HEM/ONC J9206 Camptosar hospital, HYDROCHLORIDE hematology, or oncology providers. Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9207 Ixempra IXABEPILONE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9208 Ifex; Mitoxana IFOSFAMIDE hospital, hematology, or oncology providers.
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Auth required for all providers except HEM/ONC J9209 Mesnex MESNA hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9211 Idamycin IDARUBICIN HCL hospital, hematology, or oncology providers. Auth required for all GENERAL J9212 Infergen INTERFERON ALFACON 1 providers Intron A; Auth required for all GENERAL J9214 INTERFERON ALFA 2B Rebetron Kit providers Auth required for all GENERAL J9215 Alferon N INTERFERON ALFA n3 providers Auth required for all GENERAL J9216 Actimmune INTERFERON GAMMA 1B providers Lupron Depot; Auth required for all GENERAL J9217 LEUPROLIDE ACETATE Eligard providers Auth required for all GENERAL J9218 Lupron LEUPROLIDE ACETATE providers Vantas Implant Auth required for all GENERAL J9225 HISTRELIN ACETATE Kit providers Auth required for all GENERAL J9226 Supprelin LA HISTRELIN ACETATE providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9228 Yervoy IPILIMUMAB hospital, hematology, or oncology providers. Auth required for all providers except MECHLORETHAMINE HEM/ONC J9230 Mustargen hospital, HYDROCHLORIDE hematology, or oncology providers.
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Auth required for all Alkeran; L providers except HEM/ONC J9245 phenylalanine MELPHALAN hospital, mustard hematology, or oncology providers. Auth required for all providers except HEM/ONC J9261 Arranon NELARABINE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9263 Eloxatin OXALIPLATIN hospital, hematology, or oncology providers. Auth required for all providers except PACLITAXEL: ALBUMIN- HEM/ONC J9264 Abraxane hospital, BOUND (HUMAN) hematology, or oncology providers. Auth required for all providers except Taxol; Nov HEM/ONC J9265 PACLITAXEL hospital, Onxol hematology, or oncology providers.
Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9266 Oncaspar PEGASPARGASE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9268 Nipent PENTOSTATIN hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9280 Mutamycin MITOMYCIN C hospital, hematology, or
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oncology providers.
Auth required for all MITOXANTRONE providers except HEM/ONC J9293 Novantrone HYDROCHLORIDE hematology or oncology providers. Auth required for all providers except GEMTUZUMAB HEM/ONC J9300 Mylotarg hospital, OZOGAMICIN hematology, or oncology providers. Auth required for all providers except HEM/ONC J9302 Arzerra OFATUMUMAB hospital, hematology, or oncology providers.
Auth required for all providers except HEM/ONC J9303 Vectibix PANITUMUMAB hospital, hematology, or oncology providers.
Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9305 Alimta PEMETREXED DISODIUM hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9307 Folotyn PRALATREXATE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9310 Rituxan RITUXIMAB hematology or oncology providers.
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Auth required for all providers except HEM/ONC J9315 Istodax ROMIDEPSIN hematology or oncology providers. Auth required for all providers except HEM/ONC J9320 Zanosar STREPTOZOCIN hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9328 Temodar TEMOZOLOMIDE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9330 Torisel TEMSIROLIMUS hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9340 Thioplex THIOTEPA hospital, hematology, or oncology providers. Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all providers except HEM/ONC J9351 Hycamtin TOPOTECAN hospital, hematology, or oncology providers. Auth required for all HEM/ONC J9355 Herceptin TRASTUZUMAB providers Auth required for all providers except HEM/ONC J9357 Valstar VALRUBICIN hospital, hematology, or oncology providers.
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Auth required for all providers except HEM/ONC J9360 Velban VINBLASTINE SULFATE hospital, hematology, or oncology providers. Auth required for all providers except Oncovin; HEM/ONC J9370 VINCRISTINE SULFATE hospital, Vincasar PFS hematology, or oncology providers. Auth required for all providers except HEM/ONC J9390 Navelbine VINORELBINE TARTRATE hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9395 Faslodex FULVESTRANT hospital, hematology, or oncology providers. Auth required for all providers except HEM/ONC J9600 Photofrin PORFIMER SODIUM hospital, hematology, or oncology providers. Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Auth required for all MISC J9999 MISC MISC CODES providers Feraheme Auth required for all GENERAL Q0138 FERUMOXYTOL (non ERSD) providers Feraheme Auth required for all GENERAL Q0139 FERUMOXYTOL (ERSD) providers Auth required for all providers except HEM/ONC Q2017 Vumon TENIPOSIDE hospital, hematology, or oncology providers. Auth required for all GENERAL Q2043 Provenge SIPULEUCEL-T providers
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Auth required for all GENERAL Q3025 Afluria INTERFERON BETA 1A providers Auth required for all GENERAL Q4074 Ventavis ILOPROST providers Epogen (for renal dialysis Auth required for all GENERAL Q4081 EPOETIN ALFA facilities and providers hospital use) Auth required for all GENERAL S0088 Gleevac IMATINIB MESYLATE providers Auth required for all GENERAL S0145 Pegasys PEGINTERFERON ALFA 2A providers Auth required for all GENERAL S0148 Peg-Intron PEGINTERFERON ALFA 2B providers Auth required for all GENERAL S0172 Leukeran CHLORAMBUCIL providers Auth required for all GENERAL S0175 Eulexin FLUTAMIDE providers Auth required for all GENERAL S0178 Ceenu LOMUSTINE providers PROCARBAZINE Auth required for all GENERAL S0182 Matulane HYDROCHLORIDE providers Updated PA Requirement Trade Name (if Additional (PL Codes) HCPCS Code applicable) HCPCS Desription Information Abilify Auth required for all GENERAL J0401 Maintena ARIPIPRAZOLE providers Auth required for all GENERAL J7699 Cayston AZTREONAM providers Auth required for all GENERAL J0717 Cimzia CERTOLIZUMAB PEGOL providers Auth required for all providers except hospital, hematology, or HEM/ONC J9019 Erwinaze ASPARAGINASE oncology providers. Auth required for all GENERAL J0178 Eylea AFLIBERCEPT providers FERRIC Auth required for all GENERAL J1439 Injectafer CARBOXYMALTOSE providers
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ADO-TRASTUZUMAB Auth required for all GENERAL J9354 Kadcyla EMTANSINE providers Auth required for all GENERAL J9047 Kyprolis CARFILZOMIB providers Auth required for all GENERAL J9306 Perjeta PERTUZUMAB providers Auth required for all GENERAL J7336 Qutenza CAPSAICIN providers Auth required for all GENERAL Q3028 Rebif INTERFERON BETA-1A providers METHYLNALTREXONE Auth required for all GENERAL J2212 Relistor BROMIDE providers Auth required for all GENERAL J8499 Revatio SILDENAFIL CITRATE providers Auth required for all GENERAL J9999 Cyramza RAMUCIRUMAB providers Auth required for all GENERAL J9400 Zaltrap ZIV-AFLIBERCEPT providers
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