sign in sign up
<<
Home , Romidepsin

Silverback Care Management • Care N’ Care Part B Specialty Drug Preauthorization List

The medications listed below require preauthorization when delivered in the physician office, clinic, outpatient or home setting Preauthorization is NOT required when administered as an Inpatient or in the ED or Urgent Care Clinic All drugs require preauthorization

Brand Name J-Code J-Code Description Abraxane J9264 Injection, protein-bound particles, 1 mg Actemra (IV) J3262 Injection, tocilizumab, 1 mg Adcetris J9042 Injection, brentuximab vedotin, 1 mg Adriamycin J9000 Injection, hydrochloride, 10 mg Advate J7192 Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified Adynovate J7207 Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. Afstyla J7210 Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u. Akynzeo IV C9033 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg Akynzeo IV J3490 Unclassified drugs Aldurazyme J1931 Injection, laronidase, 0.1 mg Alimta J9305 Injection, , 10 mg Aliqopa J3490 Unclassified drugs Aliqopa C9399 Unclassified drugs or biologicals Aliqopa J9999 Not otherwise classified, antineoplastic drugs Aloxi J2469 Injection, palonosetron hcl, 25 mcg Alphanate J7186 Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. AlphaNine SD J7193 Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. Alprolix J7201 Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. Aralast NP J0256 Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg Aranesp (for non-ESRD use) J0881 Injection, darbepoetin alfa, 1 microgram (non-esrd use) Arcalyst J2793 Injection, rilonacept, 1 mg Arranon J9261 Injection, , 50 mg Arzerra J9302 Injection, ofatumumab, 10 mg

1 Brand Name J-Code J-Code Description Avastin C9257 Injection, bevacizumab, 0.25 mg Avastin J9035 Injection, bevacizumab, 10 mg Aveed J3145 Injection, testosterone undecanoate, 1 mg Azedra C9399 Unclassified drugs or biologicals Azedra A4641 Radiopharmaceutical, diagnostic, not otherwise classified Bavencio J9023 Injection, avelumab, 10 mg Bebulin J7194 Factor ix, complex, per i.u. Bebulin VH J7194 Factor ix, complex, per i.u. Beleodaq J9032 Injection, , 10 mg (Belrapzo) J3490 Unclassified drugs Bendamustine (Belrapzo) C9399 Unclassified drugs or biologicals Bendamustine (Belrapzo) J9999 Not otherwise classified, antineoplastic drugs Bendeka J9034 Injection, bendamustine hcl (bendeka), 1 mg BeneFix J7195 Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified Benlysta J0490 Injection, belimumab, 10 mg Berinert J0597 Injection, c-1 esterase inhibitor (human), berinert, 10 units Besponsa J3490 Unclassified drugs Besponsa J9999 Not otherwise classified, antineoplastic drugs Besponsa C9028 Injection, inotuzumab ozogamicin, 0.1 mg Besponsa J3590 Unclassified biologics Blincyto J9039 Injection, blinatumomab, 1 microgram Brineura J3590 Unclassified biologics Brineura C9014 Injection, cerliponase alfa, 1 mg Campath J0202 Injection, alemtuzumab, 1 mg Cerezyme J1786 Injection, imiglucerase, 10 units Cimzia J0717 Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervi- sion of a physician, not for use when drug is self administered) Cinqair J2786 Injection, reslizumab, 1 mg Cinryze J0598 Injection, c-1 esterase inhibitor (human), cinryze, 10 units Cinvanti J3490 Unclassified drugs Coagedex J7199 Hemophilia clotting factor, not otherwise classified Corifact J7180 Injection, factor xiii (antihemophilic factor, human), 1 i.u. Crysvita C9399 Unclassified drugs or biologicals Crysvita J3590 Unclassified biologics Cyclokapron J3490 Unclassified drugs Cyclokapron C9399 Unclassified drugs or biologicals Cyramza J9308 Injection, ramucirumab, 5 mg

2 Brand Name J-Code J-Code Description Dacogen J0894 Injection, , 1 mg Darzalex J9145 Injection, daratumumab, 10 mg Doxil Q2050 Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg Duopa Enteral J7340 Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml Dupixent J3490 Unclassified drugs Dupixent J3590 Unclassified biologics Elaprase J1743 Injection, idursulfase, 1 mg Elelyso J3060 Injection, taliglucerase alfa, 10 units Elitek J2783 Injection, rasburicase, 0.5 mg Eloctate J7205 Injection, factor viii fc fusion protein (recombinant), per iu Eloxatin J9263 Injection, , 0.5 mg Emend IV J1453 Injection, fosaprepitant, 1 mg Empliciti J9176 Injection, elotuzumab, 1 mg Entyvio J3380 Injection, vedolizumab, 1 mg Epogen J0885 Injection, epoetin alfa, (for non-esrd use), 1000 units Epogen Q4081 Injection, epoetin alfa, 100 units (for esrd on dialysis) Erbitux J9055 Injection, cetuximab, 10 mg Erwinaze J9019 Injection, (erwinaze), 1,000 iu Evomela J9245 Injection, hydrochloride, 50 mg Exondys 51 J1428 Injection, eteplirsen, 10 mg Fabrazyme J0180 Injection, agalsidase beta, 1 mg Fasenra J3490 Unclassified drugs Fasenra J3590 Unclassified biologics Feiba NF J7198 Anti-inhibitor, per i.u. Firazyr J1744 Injection, icatibant, 1 mg Flolan J1325 Injection, epoprostenol, 0.5 mg Folotyn J9307 Injection, , 1 mg Fulphila Q5108 Injection, pegfilgrastim-jmdb, 0.5 mg Fusilev J0641 Injection, levoleucovorin calcium, 0.5 mg Gattex J3490 Unclassified drugs Gattex C9399 Unclassified drugs or biologicals Gazyva J9301 Injection, obinutuzumab, 10 mg Gemzar® J9201 Injection, hydrochloride, 200 mg Glassia J0257 Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg Granix J1447 Injection, tbo-filgrastim, 1 microgram Haegarda J3490 Unclassified drugs Haegarda J3590 Unclassified biologics

3 Brand Name J-Code J-Code Description Haegarda C9015 Injection, c-1 esterase inhibitor (human), haegarda, 10 units Halaven J9179 Injection, mesylate, 0.1 mg Helixate FS J7192 Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified Hemlibra Q9995 Injection, emicizumab-kxwh, 0.5 mg Hemofil M J7190 Factor viii (antihemophilic factor, human) per i.u. Herceptin J9355 Injection, trastuzumab, 10 mg Humate-P J7187 Injection, von willebrand factor complex (humate-p), per iu vwf:rco Idelvion J7202 Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. Ilaris J0638 Injection, canakinumab, 1 mg Illumya C9399 Unclassified drugs or biologicals Illumya J3590 Unclassified biologics Iluvien J7313 Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg Imfinzi J9999 Not otherwise classified, antineoplastic drugs Imfinzi J3590 Unclassified biologics Imfinzi C9492 Injection, durvalumab, 10 mg Imlygic J9325 Injection, talimogene laherparepvec, per 1 million plaque forming units Immune Globulin: Atgam J7504 Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg Immune Globulin: Bivigam J1556 Injection, immune globulin (bivigam), 500 mg Immune Globulin: Carimune NF® J1566 Injection, immune globulin, intravenous, lyophilized (e.g., (lypholized) powder), not otherwise specified, 500 mg Immune Globulin: Cuvitru J1555 Injection, immune globulin (cuvitru), 100 mg Immune Globulin: CytoGam J0850 Injection, cytomegalovirus immune globulin intravenous (hu- man), per vial Immune Globulin: Flebogamma J1572 Injection, immune globulin, (flebogamma/flebogamma dif), DIF® (nonlypholized) intravenous, non-lyophilized (e.g., liquid), 500 mg Immune Globulin: Gammagard J1569 Injection, immune globulin, (gammagard liquid), non-lyo- SD®/Gammagard philized, (e.g., liquid), 500 mg Immune Globulin: Gammaked J1561 Injection, immune globulin, (gamunex-c/gammaked), non-lyo- philized (e.g., liquid), 500 mg Immune Globulin: Gammaplex® J1557 Injection, immune globulin, (gammaplex), intravenous, non-ly- ophilized (e.g., liquid), 500 mg Immune Globulin: Gammunex-C J1561 Injection, immune globulin, (gamunex-c/gammaked), non-lyo- philized (e.g., liquid), 500 mg Immune Globulin: Hizentra J1559 Injection, immune globulin (hizentra), 100 mg

4 Brand Name J-Code J-Code Description Immune Globulin: Hyqvia J1575 Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin Immune Globulin: Octagam J1568 Injection, immune globulin, (octagam), intravenous, non-lyo- philized (e.g., liquid), 500 mg Immune Globulin: Panglobulin NF J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg Immune Globulin: Privigen J1459 Injection, immune globulin (privigen), intravenous, non-lyo- philized (e.g., liquid), 500 mg Immune Globulin: Varizig J9999 Not otherwise classified, antineoplastic drugs Immune Globulin: Vivaglobulin J1562 Injection, immune globulin (vivaglobin), 100 mg Inflectra Q5103 Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg Istodax J9315 Injection, romidepsin, 1 mg Ixempra J9207 Injection, , 1 mg Ixinity J7195 Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified Jevtana J9043 Injection, , 1 mg Jivi J7199 Hemophilia clotting factor, not otherwise classified Kadcyla J9354 Injection, ado-trastuzumab emtansine, 1 mg Kalbitor J1290 Injection, ecallantide, 1 mg Kanuma J2840 Injection, sebelipase alfa, 1 mg Kcentra J3590 Unclassified biologics Kcentra C9132 Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity Keytruda J9271 Injection, pembrolizumab, 1 mg Koate-DVI J7190 Factor viii (antihemophilic factor, human) per i.u. Kogenate FS J7192 Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified Kovaltry J7211 Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u. Krystexxa J2507 Injection, pegloticase, 1 mg Kymriah Q2040 Tisagenlecleucel, up to 250 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion Kyprolis J9047 Injection, , 1 mg Kytril J1626 Injection, granisetron hydrochloride, 100 mcg Lartruvo J9285 Injection, olaratumab, 10 mg Lemtrada J0202 Injection, alemtuzumab, 1 mg Leukine J2820 Injection, sargramostim (gm-csf), 50 mcg Lipodox Q2049 Injection, doxorubicin hydrochloride, liposomal, imported lipodox, 10 mg

5 Brand Name J-Code J-Code Description Lumizyme J0221 Injection, alglucosidase alfa, (lumizyme), 10 mg Lutathera J3490 Unclassified drugs Lutathera C9399 Unclassified drugs or biologicals Lutathera J9999 Not otherwise classified, antineoplastic drugs Lutathera J3590 Unclassified biologics Luxturna J3490 Unclassified drugs Luxturna C9399 Unclassified drugs or biologicals Luxturna J3590 Unclassified biologics Macugen J2503 Injection, pegaptanib sodium, 0.3 mg Marqibo kit J9371 Injection, sulfate liposome, 1 mg Mepsevii J3590 Unclassified biologics Mircera (SQ) J0888 Injection, epoetin beta, 1 microgram, (for non esrd use) Monoclate-P J7190 Factor viii (antihemophilic factor, human) per i.u. Mononine J7193 Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. Mozobil J2562 Injection, plerixafor, 1 mg Mvasi J3590 Unclassified biologics Mylotarg J9203 Injection, gemtuzumab ozogamicin, 0.1 mg Naglazyme J1458 Injection, galsulfase, 1 mg Neulasta J2505 Injection, pegfilgrastim, 6 mg Neulasta Onpro J2505 Injection, pegfilgrastim, 6 mg Neupogen J1442 Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram Nivestym Q5110 Injection, filgrastim -aafi, biosimilar (nivestym), 1 mcg NovoEight J7182 Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu NovoSeven RT J7189 Factor viia (antihemophilic factor, recombinant), per 1 micro- gram Nplate J2796 Injection, romiplostim, 10 micrograms Nucala J2182 Injection, mepolizumab, 1 mg Nulojix J0485 Injection, belatacept, 1 mg Nuwiq J7209 Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. Obizur J7188 Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. Ocrevus J2350 Injection, ocrelizumab, 1 mg Oncaspar J9266 Injection, , per single dose vial Onivyde J9205 Injection, liposome, 1 mg Onpattro J3490 Unclassified drugs Onpattro C9399 Unclassified drugs or biologicals Opdivo J9299 Injection, nivolumab, 1 mg

6 Brand Name J-Code J-Code Description Orencia IV J0129 Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) Ozurdex J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg Palynziq J3490 Unclassified drugs Palynziq J3590 Unclassified biologics Perjeta J9306 Injection, pertuzumab, 1 mg Portrazza J9295 Injection, necitumumab, 1 mg Poteligeo J3490 Unclassified drugs Poteligeo C9399 Unclassified drugs or biologicals Poteligeo J9999 Not otherwise classified, antineoplastic drugs Poteligeo J3590 Unclassified biologics Prevymis J3490 Unclassified drugs Prialt J2278 Injection, ziconotide, 1 microgram Probuphine J0570 Buprenorphine implant, 74.2 mg Procrit J0885 Injection, epoetin alfa, (for non-esrd use), 1000 units Procrit Q4081 Injection, epoetin alfa, 100 units (for esrd on dialysis) Profilnine J7194 Factor ix, complex, per i.u. Prolastin-C J0256 Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg Provenge® Q2043 Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion Qutenza J7336 8% patch, per square centimeter Radicava C9493 Injection, edaravone, 1 mg Rebinyn J7195 Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified Rebinyn J3590 Unclassified biologics Recombinate J7192 Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified Remicade J1745 Injection, infliximab, excludes biosimilar, 10 mg Remodulin J3285 Injection, treprostinil, 1 mg Renflexis Q5104 Injection, infliximab-abda, biosimilar, (renflexis), 10 mg Retacrit Q5106 Injection, epoetin alfa, biosimiliar (Retacrit), for non-ESRD use, 100 units Retisert J7311 Fluocinolone acetonide, intravitreal implant Revatio J3490 Unclassified drugs Rituxan J9310 Injection, rituximab, 100 mg Rituxan Hyclea J3490 Unclassified drugs Rituxan Hyclea J9999 Not otherwise classified, antineoplastic drugs

7 Brand Name J-Code J-Code Description Rituxan Hyclea J3590 Unclassified biologics Rituxan Hyclea C9467 Injection, rituximab and hyaluronidase, 10 mg Rixubis J7200 Injection, factor ix, (antihemophilic factor, recombinant), rixu- bis, per iu Ruconest J0596 Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units Sandostatin LAR J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg Signifor LAR J2502 Injection, pasireotide long acting, 1 mg Simponi/Simponi ARIA J1602 Injection, golimumab, 1 mg, for intravenous use Soliris J1300 Injection, eculizumab, 10 mg Somatuline Depot J1930 Injection, lanreotide, 1 mg Spinraza J2326 Injection, nusinersen, 0.1 mg Stelara IV J3358 Ustekinumab, for intravenous injection, 1 mg Sublocade Q9991 Injection, buprenorphine ER (Sublocade), less than or equal to 100 mg Sublocade Q9992 Injection, buprenorphine ER (Sublocade), greater than 100 mg Sustol J1627 Injection, granisetron, extended-release, 0.1 mg Sylvant J2860 Injection, siltuximab, 10 mg Synagis 90378 Respiratory syncytial virus, monoclonal antibody, recombi- nant, for intramuscular use, 50 mg, each Synribo J9262 Injection, omacetaxine mepesuccinate, 0.01 mg Tecentriq J9022 Injection, atezolizumab, 10 mg Temodar J9328 Injection, , 1 mg Testopel S0189 Testosterone pellet, 75 mg Thrombate III J7197 Antithrombin iii (human), per i.u. Torisel (brand only) J9330 Injection, temsirolimus, 1 mg Treanda J9033 Injection, bendamustine hcl (treanda), 1 mg Tretten J7181 Injection, factor xiii a-subunit, (recombinant), per iu Triptodur ER C9016 Injection, triptorelin extended release, 3.75 mg Trisenox J9017 Injection, , 1 mg Tysabri J2323 Injection, natalizumab, 1 mg Tyvaso J7686 Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg Unitxin J9999 Not otherwise classified, antineoplastic drugs Valstar J9357 Injection, , intravesical, 200 mg Varubi J3490 Unclassified drugs Vectibix J9303 Injection, panitumumab, 10 mg Velcade J9041 Injection, , 0.1 mg

8 Brand Name J-Code J-Code Description Veletri J1325 Injection, epoprostenol, 0.5 mg Ventavis Q4074 Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms Vidaza J9025 Injection, , 1 mg Vimizim J1322 Injection, elosulfase alfa, 1 mg Visudyne J3396 Injection, , 0.1 mg Vonvendi J7179 Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco Vpriv J3385 Injection, velaglucerase alfa, 100 units Vyxeos C9024 Injection, liposomal, 1 mg and 2.27 mg cytara- bine Wilate J7183 Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco Xofigo A9606 Radium ra-223 dichloride, therapeutic, per microcurie Xolair J2357 Injection, omalizumab, 5 mg Xyntha J7185 Injection, factor viii (antihemophilic factor, recombinant) (xyn- tha), per i.u. Yervoy J9228 Injection, ipilimumab, 1 mg Yescarta Q2041 Axicabtagene Ciloleucel, up to 200 million autologous An- ti-CD19 CAR T Cells, Including leukapheresis and dose prepa- ration procedures, per infusion Yondelis J9352 Injection, , 0.1 mg Zaltrap J9400 Injection, ziv-aflibercept, 1 mg Zarxio Q5101 Injection, filgrastim (g-csf), biosimilar, 1 microgram Zemaira J0256 Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg Zevalin A9543 Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treat- ment dose, up to 40 millicuries Zilretta Q9993 Injection, triamcinolone acetonide, preservativefree, extend- ed-release, microsphere formulation, 1 mg Zinplava J0565 Injection, bezlotoxumab, 10 mg Zofran IV J2405 Injection, ondansetron hydrochloride, per 1 mg #N/A J0640 Injection, leucovorin calcium, per 50 mg #N/A J1675 Injection, histrelin acetate, 10 micrograms #N/A J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg #N/A J9015 Injection, aldesleukin, per single use vial #N/A J9027 Injection, , 1 mg #N/A J9031 Bcg (intravesical) per instillation #N/A J9040 Injection, sulfate, 15 units

9 Brand Name J-Code J-Code Description #N/A J9045 Injection, , 50 mg #N/A J9050 Injection, , 100 mg #N/A J9060 Injection, , powder or solution, 10 mg #N/A J9065 Injection, , per 1 mg #N/A J9070 , 100 mg #N/A J9098 Injection, liposome, 10 mg #N/A J9100 Injection, cytarabine, 100 mg #N/A J9120 Injection, , 0.5 mg #N/A J9130 , 100 mg #N/A J9150 Injection, daunorubicin, 10 mg #N/A J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg #N/A J9155 Injection, degarelix, 1 mg #N/A J9171 Injection, , 1 mg #N/A J9178 Injection, hcl, 2 mg #N/A J9181 Injection, , 10 mg #N/A J9185 Injection, phosphate, 50 mg #N/A J9190 Injection, , 500 mg #N/A J9200 Injection, , 500 mg #N/A J9206 Injection, irinotecan, 20 mg #N/A J9208 Injection, , 1 gram #N/A J9209 Injection, mesna, 200 mg #N/A J9211 Injection, hydrochloride, 5 mg #N/A J9213 Injection, interferon, alfa-2a, recombinant, 3 million units #N/A J9214 Injection, interferon, alfa-2b, recombinant, 1 million units #N/A J9230 Injection, mechlorethamine hydrochloride, (nitrogen mus- tard), 10 mg #N/A J9250 sodium, 5 mg #N/A J9260 Methotrexate sodium, 50 mg #N/A J9267 Injection, paclitaxel, 1 mg #N/A J9268 Injection, , 10 mg #N/A J9280 Injection, mitomycin, 5 mg #N/A J9293 Injection, hydrochloride, per 5 mg #N/A J9320 Injection, streptozocin, 1 gram #N/A J9340 Injection, , 15 mg #N/A J9351 Injection, , 0.1 mg #N/A J9360 Injection, sulfate, 1 mg #N/A J9370 Vincristine sulfate, 1 mg #N/A J9390 Injection, tartrate, 10 mg #N/A J9600 Injection, , 75 mg

10 Brand Name J-Code J-Code Description #N/A Q3028 Vincristine sulfate, 1 mg #N/A Q5102 Injection, infliximab, biosimilar, 10 mg

11