June 2020 MEDICATIONS TO REQUIRE MEDICAL PRIOR AUTHORIZATION,

EFFECTIVE July 1, 2020

As a part of our continuous efforts to improve the quality of care for our members, Gateway Health will require prior authorization for the following medications effective with dates of service beginning July 1, 2020. This authorization requirement applies to Medicare Assured members. Failure to obtain authorization will result in a claim denial.

Medical necessity criteria for each of the medications listed below are outlined in the specific medication policies available online. To access Gateway Health medication policies, please paste the following link in your internet browser: https://www.gatewayhealthplan.com/provider/medicare-resources/medicare-medical-policy.

PROCEDURE CODES REQUIRING AUTHORIZATION Procedure Description Procedure Description Code Code Nivestym Injection, filgrastim-aafi, biosimilar, (nivestym), J2469 Aloxi Injection, palonosetron hcl, 25 mcg Q5110 1 microgram Aranesp Injection, darbepoetin alfa, 1 J0881 J2796 Nplate Injection, romiplostim, 10 micrograms) microgram (non-esrd use) J0567 Brineura Injection, cerliponase alfa, 1 mg J2350 Ocrevus Injection, ocrelizumab, 1 mg Octagam Injection, immune globulin, (octagam), J1786 Cerezyme Injection, imiglucerase, 10 units J1568 intravenous, non-lyophilized (e.g., liquid), 500 mg J0185 Cinvanti Injection, aprepitant, 1 mg J2278 Prialt Injection, ziconotide, 1 microgram Privigen Injection, immune globulin (privigen), J1453 Emend Injection, fosaprepitant, 1 mg J1459 intravenous, non-lyophilized (e.g., liquid), 500 mg Epogen Injection, epoetin alfa, (for non-esrd Procrit Injection, epoetin alfa, (for non-esrd use), 1000 J0885 J0885 use), 1000 units units Retacrit Injection, epoetin alfa-epbx, biosimilar, (retacrit) J1428 Exondys 51 Injection, eteplirsen, 10 mg Q5106 (for non-esrd use), 1000 units Fulphila Injection, pegfilgrastim-jmdb, Q5108 J9312 Rituxan Injection, rituximab, 10 mg biosimilar, (fulphila), 0.5 mg Gammaked; Gamunex-C Injection, immune Sandostatin LAR depot Injection, octreotide, depot form J1561 globulin, (gamunex-c/gammaked), non- J2353 for intramuscular injection, 1 mg lyophilized (e.g., liquid), 500 mg Gammaplex Injection, immune globulin, J1557 (gammaplex), intravenous, non-lyophilized J1300 Soliris Injection, eculizumab, 10 mg (e.g., liquid), 500 mg Hizentra Injection, immune globulin (hizentra), J1559 J1930 Somatuline depot Injection, lanreotide, 1 mg 100 mg Hyqvia Injection, immune J1575 globulin/hyaluronidase, (hyqvia), 100 mg J2326 Spinraza Injection, nusinersen, 0.1 mg immunoglobulin Gammagard S/D; Carimune NF Injection, Truxima Injection, rituximab-abbs, biosimilar, (truxima), J1566 immune globulin, intravenous, lyophilized (e.g., Q5115 10 mg powder), not otherwise specified, 500 mg Panzyga; Asceniv Injection, immune J1599 globulin, intravenous, non-lyophilized (e.g., J2323 Tysabri Injection, natalizumab, 1 mg liquid), not otherwise specified, 500 mg Leukine Injection, sargramostim (gm-csf), 50 Udenyca Injection, pegfilgrastim-cbqv, biosimilar, J2820 Q5111 mcg (udenyca), 0.5 mg Lumizyme Injection, alglucosidase alfa, J0221 J1303 Ultomiris Injection, ravulizumab-cwvz, 10 mg (lumizyme), 10 mg Lupron Depot Injection, leuprolide acetate J1950 J9041 Velcade Injection, bortezomib (velcade), 0.1 mg (for depot suspension), per 3.75 mg Eligard; Lupron Depot Leuprolide acetate J9217 J1322 Vimizim Injection, elosulfase alfa, 1 mg (for depot suspension), 7.5 mg Luxturna Injection, voretigene neparvovec-rzyl, Vonvendi Injection, von willebrand factor (recombinant), J3398 J7179 1 billion vector genomes (vonvendi), 1 i.u. vwf:rco Mircera Injection, epoetin beta, 1 microgram, Zarxio Injection, filgrastim-sndz, biosimilar, (zarxio), 1 J0888 Q5101 (for non esrd use microgram Mvasi Injection, bevacizumab-awwb, Q5107 J9202 Zoladex Goserelin acetate implant, per 3.6 mg biosimilar, (mvasi), 10 mg J2505 Neulasta Injection, pegfilgrastim, 6 mg J3590* Zolgensma onasemnogene abeparvovec-xioi Neupogen Injection, filgrastim (g-csf), J1442 excludes biosimilars, 1 microgram *These medications will be reviewed under the applicable miscellaneous procedure code J3490, J3590, or J9999 until a permanent code is assigned

ADDITIONAL INFORMATION  Any decision to deny a prior authorization is made by a licensed pharmacist based on individual member needs, characteristics of the local delivery system, and established clinical criteria.  NaviNet is the most efficient means to request authorization. A new NaviNet form with autofill functionality will be added to the Authorization Request Forms to make completing and submitting your online requests easier and faster.  The prior authorization look up tool (accessed via NaviNet) will be updated to show prior authorization requirements for these medications.  For a smooth transition to the prior authorization process, you may begin to submit authorization requests beginning June 24, 2020 for dates of service on July 1, 2020 and beyond.  Authorization does not guarantee payment of claims. Medications listed above will be reimbursed by Gateway Health only if it is medically necessary, a covered service, and provided to an eligible member.  Non-covered benefits will not be paid unless special circumstances exists. Always review member benefits to determine covered and non-covered services.

If you have questions regarding the authorization process and how to submit authorizations electronically, please contact your Gateway Health Provider Relations Representative directly or Gateway Health Pharmacy Services using the phone number 1-800-685-5209.