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Kentucky Medicaid Physician Administered Drug List (PDF)

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Kentucky Medicaid Physician Administered Drug List (PDF) Please be advised that this list is not intended to be an all-inclusive list of covered services or authorization requirements under WellCare of Kentucky Health Plans, Inc.. It provides information regarding prior authorization requirements that were generally accurate as of the published date of the document. The most accurate method of looking up and submitting verifying authorization requirements is by utilizing the WellCare Secure Provider Portal Kentucky Medicaid Physician Administered Drug List Code Description Current Role Note 90281 IMMUNE GLOBULIN (IG), HUMAN, FOR INTRAMUSCULAR USE No Auth Required 90283 IMMUNE GLOBULIN (IGIV), HUMAN, FOR INTRAVENOUS USE No Auth Required 90284 IMMUNE GLOBULIN (SCIG), HUMAN, FOR USE IN SUBCUTANEOUS INFUSIONS, 100 MG, EACH No Auth Required 90287 BOTULINUM ANTITOXIN, EQUINE, ANY ROUTE Re-direct to Pharmacy department 90288 BOTULISM IMMUNE GLOBULIN, HUMAN, FOR INTRAVENOUS USE Re-direct to Pharmacy department 90291 CYTOMEGALOVIRUS IMMUNE GLOBULIN (CMV-IGIV), HUMAN, FOR INTRAVENOUS USE Re-direct to Pharmacy department 90296 DIPHTHERIA ANTITOXIN, EQUINE, ANY ROUTE No Auth Required 90371 HEPATITIS B IMMUNE GLOBULIN (HBIG), HUMAN, FOR INTRAMUSCULAR USE No Auth Required 90375 RABIES IMMUNE GLOBULIN (RIG), HUMAN, FOR INTRAMUSCULAR AND/OR SUBCUTANEOUS USE No Auth Required 90376 RABIES IMMUNE GLOBULIN, HEAT-TREATED (RIG-HT), HUMAN, FOR INTRAMUSCULAR AND/OR SUBCUTANEOUS USE No Auth Required 90378 RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN (RSV-IGIM), FOR INTRAMUSCULAR USE, 50 MG, EACH Re-direct to Pharmacy department 90384 RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, FULL-DOSE, FOR INTRAMUSCULAR USE No Auth Required 90385 RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, MINI-DOSE, FOR INTRAMUSCULAR USE No Auth Required 90386 RHO(D) IMMUNE GLOBULIN (RHIGIV), HUMAN, FOR INTRAVENOUS USE No Auth Required 90389 TETANUS IMMUNE GLOBULIN (TIG), HUMAN, FOR INTRAMUSCULAR USE No Auth Required 90393 VACCINIA IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE No Auth Required 90396 VARICELLA-ZOSTER IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE No Auth Required 90399 UNLISTED IMMUNE GLOBULIN Re-direct to Pharmacy department 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFI No Auth Required 90461 EACH ADDITIONAL VACCINE/TOXOID COMPONENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) No Auth Required 90471 IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); ONE VACCINE ( No Auth Required 90472 IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITION No Auth Required 90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; ONE VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) No Auth Required 90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (L No Auth Required 90476 ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE No Auth Required 90477 ADENOVIRUS VACCINE, TYPE 7, LIVE, FOR ORAL USE No Auth Required 90581 ANTHRAX VACCINE, FOR SUBCUTANEOUS USE No Auth Required 90585 BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUBERCULOSIS, LIVE, FOR PERCUTANEOUS USE No Auth Required 90586 BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR BLADDER CANCER, LIVE, FOR INTRAVESICAL USE No Auth Required 90620 MENB RECOMBINANT PROT WITHOUT MEMBR VESIC VACC IM No Auth Required 90621 MENB RECOMBINANT LIPOPROTEIN VACCINE IM No Auth Required 90625 CHOLERA VACCINE, LIVE, ADULT DOSAGE, 1 DOSE SCHEDULE, FOR ORAL USE No Auth Required 90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use No Auth Required 90632 HEPATITIS A VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE No Auth Required 90633 HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE No Auth Required 90634 HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE No Auth Required 90636 HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT DOSAGE, FOR INTRAMUSCULAR USE No Auth Required 90644 MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS C & Y AND HEMOPHILUS INFLUENZA B VACCINE, TETANUS TOXOID CONJUGATE (HIB-MENCY-TT), 4-D No Auth Required 90647 HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-OMP CONJUGATE (3 DOSE SCHEDULE), FOR INTRAMUSCULAR USE No Auth Required 90648 HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-T CONJUGATE (4 DOSE SCHEDULE), FOR INTRAMUSCULAR USE No Auth Required 90649 HUMAN PAPILLOMA VIRUS (HPV) VACCINE, TYPES 6, 11, 16, 18 (QUADRIVALENT), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE No Auth Required 90650 HUMAN PAPILLOMAVIRUS (HPV) VACCINE, TYPES 16 AND 18, BIVALENT, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE No Auth Required 90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 3 dose schedule, for intramuscular use No Auth Required 90653 INFLUENZA VACCINE, INACTIVATED, SUBUNIT, ADJUVANTED, FOR INTRAMUSCULAR USE No Auth Required 90654 Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use No Auth Required 90655 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN 6-35 MONTHS OF AGE, FOR INTRAMUSCUL No Auth Required 1 90656 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS AND OLDER, FOR INTRAMUSC No Auth Required 90657 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO CHILDREN 6-35 MONTHS OF AGE, FOR INTRAMUSCULAR USE No Auth Required 90658 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE No Auth Required 90660 INFLUENZA VIRUS VACCINE, LIVE, FOR INTRANASAL USE No Auth Required 90661 INFLUENZA VIRUS VACCINE, DERIVED FROM CELL CULTURES, SUBUNIT, PRESERVATIVE AND ANTIBIOTIC FREE, FOR INTRAMUSCULAR USE No Auth Required 90662 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAM No Auth Required 90664 INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION, LIVE, FOR INTRANASAL USE No Auth Required 90666 INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION, SPLIT VIRUS, PRESERVATIVE FREE, FOR INTRAMUSCULAR USE No Auth Required 90667 INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION, SPLIT VIRUS, ADJUVANTED, FOR INTRAMUSCULAR USE No Auth Required 90668 INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION, SPLIT VIRUS, FOR INTRAMUSCULAR USE No Auth Required 90670 PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT, FOR INTRAMUSCULAR USE No Auth Required 90672 INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE, FOR INTRANASAL USE No Auth Required 90673 INFLUENZA VIRUS VACCINE, TRIVALENT, DERIVED FROM RECOMBINANT DNA (RIV3), HEMAGGLUTININ (HA) PROTEIN ONLY, PRESERVATIVE AND ANTIBIO No Auth Required 90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use No Auth Required 90675 RABIES VACCINE, FOR INTRAMUSCULAR USE No Auth Required 90676 RABIES VACCINE, FOR INTRADERMAL USE No Auth Required 90680 ROTAVIRUS VACCINE, PENTAVALENT, 3 DOSE SCHEDULE, LIVE, FOR ORAL USE No Auth Required 90681 ROTAVIRUS VACCINE, HUMAN, ATTENUATED, 2 DOSE SCHEDULE, LIVE, FOR ORAL USE No Auth Required 90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use No Auth Required 90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN 6-35 MONTHS OF AGE, FOR INTRA No Auth Required 90686 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, No Auth Required 90687 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, WHEN ADMINISTERED TO CHILDREN 6-35 MONTHS OF AGE, FOR INTRAMUSCULAR USE No Auth Required 90688 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR U No Auth Required 90689 Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use No Auth Required 90690 TYPHOID VACCINE, LIVE, ORAL No Auth Required 90691 TYPHOID VACCINE, VI CAPSULAR POLYSACCHARIDE (VICPS), FOR INTRAMUSCULAR USE No Auth Required 90694 Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use No Auth Required 90696 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND POLIOVIRUS VACCINE, INACTIVATED (DTAP-IPV), WHEN ADMINISTERED No Auth Required 90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB),No Auth Required for intramuscular use 90698 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZA TYPE B, AND POLIOVIRUS VACCINE, INACTIVATE No Auth Required 90700 DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS No Auth Required 90702 DIPHTHERIA AND TETANUS TOXOIDS (DT) ADSORBED WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE No Auth Required 90707 MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE No Auth Required 90710 MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV),
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