Together with CCHP's Medication List Prior Authorization Is Required If Indicated by X(PA)
Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes J3365 Abbokinase INJECTION, UROKINASE, 250,000 IU X J0287 Abelcet INJECTION, AMPHOTERICIN B LIPID X COMPLEX, 10 MG J0401 Abilify Maintena INJECTION, ARIPIPRAZOLE, EXTENDED X X May bIll eIther RELEASE, 1 MG (PA < 12 YEARS OF benefIt, PA AGE) reQuIred when bIllIng through pharmacy INJECTION, PACLITAXEL PROTEIN- J9264 Abraxane BOUND PARTICLES, 1 MG X J7613 Accuneb ALBUTEROL, INHALATION SOLUTION, X FDA- APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG J0132 Acetadote INJECTION, ACETYLCYSTEINE, 100 MG X J7608 Acetylcysteine ACETYLCYSTEINE, INHALATION X SOLUTION, FDA- APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER G J3262 Actemra INJECTION, TOCILIZUMAB, 1 MG X (PA) J0800 Acthar Gel INJECTION, CORTICOTROPIN, UP TO 40 X (PA) UNITS J0795 Acthrel INJECTION, CORTICORELIN OVINE X TRIFLUTATE, 1 MCG J9216 Actimmune INTERFERON GAMMAM 1-B X (PA) J2997 Activase INJECTION, ALTEPLASE RECOMBINANT, X 1 MG J2504 Adagen PEGADEMASE BOVINE 25 IU X (PA) J2062 Adasuve LoxapIne, InhalatIon powder, 10 mg X INJECTION, BRENTUXIMAB VEDOTIN, 1 J9042 Adcetris X MG 1 Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations
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