PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Last update: September 2021
Background: HCPCS codes (J-codes) can be administered through a member’s medical or pharmacy benefit. A few important notes: If administered through the Pharmacy benefit, the drug must be obtained through Accredo Specialty Pharmacy unless the drug is a “limited distribution” drug and then the pharmacy through whom it can be obtained is noted below. • If the code you are looking for is not found on this list, please search by drug name (brand name) here AND on the Pharmacy Prior Authorization list found on https://main.myconnecticare.com/~/media/files/pharmacycentral/formularypalists.pdf?la=en • J3490, J3590 and J9999 are miscellaneous codes assigned to drugs that do not have a unique code assigned. Please search by drug brand name. • This list is subject to change on a routine basis.
* Please note, the list is sorted by Drug Name.
To see if a specific drug is on this list, click on a letter and browse the table alphabetically.
A • B • C • D • E • F • G • H • I • J • K • L • M • N • O • P • Q • R • S • T • U • V • W • X • Y • Z
Or, click on this Search button and enter the name of the drug in the pop-up task pane.
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J9999/C9399 Abecma (idecabtagene vicleucel)
J9264 Abraxane (paclitaxel protein bound) J3262 Actemra (tocilizumab)
J9216 Actimmune (interferon, gamma- 1b) J0791 Adakveo (crizanlizumab-tmca)
J2062 Adasuve (loxapine for inhalation)
J9042 Adcetris (brentuximab vedotin) Seagen Secure
J9000 Adriamycin (doxorubicin)
J9190 Adrucil (fluorouracil)
J3590/C9399* Aduhelm (aducanumab-avwa)* *Not Covered by *Not Covered by ConnectiCare Commercial ConnectiCare Commercial J7192 Advate (factor VIII)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 1 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J7207 Adynovate (factor VIII)
J7210 Afstyla (factor VIII)
J3031 Ajovy (fremanezumab-vfrm)
J1454 Akynzeo (fosnetupitant/palonosetron) J1931 Aldurazyme (laronidase)
J9215 Alferon (Interferon Alfa-N3)
J9305 Alimta (pemetrexed)
J9057 Aliqopa (Copanlisib)
J9245 Alkeran (melphalan)
J2469 Aloxi (palonosetron HCl)
J7186 Alphanate (Factor VIII/VWF)
J7193 AlphaNine SD (Factor IX)
J7201 Alprolix (Factor IX)
J1426 Amondys 45 (casimersen)
J0364 Apokyn (apomorphine HCl)
J0256 Aralast (Alpha-1 proteinase inhibitor) J0881 Aranesp (darbepoetin alfa – non esrd) J2793 Arcalyst (rilonacept)
J2430 Aredia (Pamidronate Disodium)
J9261 Arranon (nelarabine)
J9302 Arzerra (ofatumumab)
J1554 Asceniv (immune globulin)
J9118 Asparlas (calaspargase pegol- mknl)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 2 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J9035 Avastin (bevacizumab)
J3145 Aveed (testosterone Acaria, CVS/ CareMark, undecanoate) Diplomat, Prime Therapeutics, iCore, Walgreen Q5121 Avsola (infliximab-axxq, biosimilar) A9590 Azedra (iodine i-131 iobenguane)
J3490/C9399 Barhemsys (amisulpride)
J9023 Bavencio (avelumab)
J3490/C9462 Baxdela (delafloxacin)
J7194 Bebulin (Factor IX Complex)
J9032 Beleodaq (belinostat)
J9036 Belrapzo (bendamustine hydrochloride) J9034 Bendeka (bendamustine HCl)
J7195 BeneFIX (Factor IX recombinant)
J0490 Benlysta (belimumab)
J0179 Beovu (brolucizumab-dbll)
J0597 Berinert (C-1 esterase inhibitor)
J9229 Besponsa (inotuzumab ozogamicin) J9050 BICNU (carmustine)
J9037 Blenrep (belantamab mafodotin- blmf) J9040 Blenoxane (bleomycin sulfate)
J9039 Blincyto (blinatumomab)
J1740 Boniva (ibandronate sodium)
J0585 Botox (onabotulinumtoxinA)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 3 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies Q2054 Breyanzi (lisocabtagene maraleucel) J0567 Brineura (cerliponase alfa)
J0594 Busulfex (Busulfan)
J0741 Cabenuva (cabotegravir and rilpivirine) J3590/C9047 Cablivi (caplacizumab-yhdp)
J0202 Campath (alemtuzumab)
J9206 Camptosar (irinotecan)
J1786 Cerezyme (imiglucerase) Professional Homecare
J0717 Cimzia (certolizumab pegol)
J2786 Cinqair (reslizumab)
J0598 Cinryze (C1 esterase inhibitor)
J0185 Cinvanti (aprepitant)
J9027 Clolar (clofarabine)
J7175 Coagadex (factor X, human)
Q9977 Compounded Drugs, NOS
J7180 Corifact (factor XIII)
J1448 Cosela (trilaciclib)
J9120 Cosmegen (dactinomycin)
J0584 Crysvita (burosumab-twza)
J1555 Cuvitru (IVIG subcutaneous)
J9308 Cyramza (ramucirumab) Biologics
J9100 Cytosar-U (cytarabine)
J9070 Cytoxan (cyclophosphamide)
J9130 DTIC-DOME (dacarbazine)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 4 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J0894 Dacogen (decitabine)
J9348 Danyelza (naxitamab-gqgk)
J9145 Darzalex (daratumumab)
J9144 Darzalex Faspro (daratumumab and hyaluronidase-fihj) J9150 Daunorubicin
J1096 Dextenza (dexamethasone)
J1095 Dexycu (dexamethasone)
Q2050 Doxil (doxorubicin hydrochloride, liposomal) J7318 Durolane (Hyaluronan or derivative) J7351 Durysta (bimatoprost, intracameral implant) J0586 Dysport (abobotulinumtoxinA)
J3590/C9399 Egrifta (tesamorelin) CVS/CareMark, Prescription Solutions, Right Source, Walgreen J1743 Elaprase (idursulfase)
J3060 Elelyso (taliglucerase alfa) Dohmen
J9178 Ellence (epirubicin)
J9175 Elliotts’ B Solution
J7205 Eloctate (Factor VIII - recombinant) J9263 Eloxatin (oxaliplatin)
J9269 Elzonris (tagraxofusp-erzs)
J1453 Emend (Fosaprepitant)
J3490 Empaveli (pegcetacoplan)
J9176 Empliciti (elotuzumab)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 5 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J9358 Enhertu (fam-trastuzumab deruxtecan-nxki) J3380 Entyvio (vedolizumab)
J0885 Epogen (epoetin alfa)
J9055 Erbitux (cetuximab)
J7204 Esperoct (factor viii, antihemophilic factor (recombinant), glycopegylated- exei) J9019 Erwinaze (asparaginase)
J7323 Euflexxa (Hyaluronan or derivative) J3111 Evenity (romosozumab-aqqg)
J1305 Evkeeza (evinacumab-dgnb)
J9246 Evomela (Melphalan)
J1428 Exondys 51 (eteplirsen)
J0178 Eylea (Aflibercept)
J0180 Fabrazyme (agalsidase beta) Professional Homecare
J7194 Factor IX
J7190-J7192 Factor VIII antihemophilic factor
J7180 Factor XIII
J0517 Fasenra (benralizumab)
J9395 Faslodex (fulvestrant)
J7198 Feiba NF (Anti-inhibitor)
J1951 Fensolvi (Leuprolide)
J0693 and J0699 Fetroja (cefiderocol)
J1744 Firazyr (icatibant)
J9155 Firmagon (degarelix)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 6 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J1325 Flolan/Veletri (epoprostenol)
J9200 Fudr (floxuridine)
J9185 Fludarabine (fludarabine phosphate) J9307 Folotyn (pralatrexate)
Q5108 Fulphila (pegfilgrastim-jmdb)
J0641 Fusilev (levoleucovorin)
J9210 Gamifant (emapalumab-izsg)
J3490/C9399 Gattex (teduglutide)
J9301 Gazyva (obinutuzumab)
J7326 Gel-One (Hyaluronan or derivative) J7328 Gelsyn-3 (Hyaluronan or derivative) J9201 Gemzar (gemcitabine hydrochloride) J7320 GenVisc 850 (Hyaluronan or derivative) J0223 Givlaari (givosiran)
J0257 Glassia (alpha-1-proteinase inhibitor–human) J1447 Granix (tbo-filgrastim)
J0599 Haegarda (c-1 esterase inhibitor, human) J9179 Halaven (eribulin mesylate)
J7192 Helixate (antihemophilic factor, recombinant) J7170 Hemlibra (emicizumab-kxwh)
J7190 Hemofil M (factor VIII- antihemophilic factor, human) J7199 Hemophilia clotting factor, NOS
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 7 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J1573-IV formula Hepagam B (Hepatitis B immune J1571-IM formula globulin) J9355 Herceptin (trastuzumab)
J9356 Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Q5113 Herzuma (trastuzumab-pkrb)
J1559 Hizentra (IVIG)
J0800 HP Acthar (corticotropin)
J7187 Humate-P (Von Willebrand factor)
J7321 Hyalgan (hyaluronan or derivative) J9351 Hycamtin (topotecan)
J7322 Hymovis (hyaluronan or derivative) J1575 Hyqvia (IVIG subcutaneous)
J9211 Idamycin (idarubicin hydrochloride) J7202 Idelvion (factor IX, albumin fusion protein, recombinant) J9208 Ifex (ifosfamide)
J0638 Ilaris (canakinumab)
J3245 Ilumya (tildrakizumab)
J7313 Iluvien (fluocinolone acetonide intravitreal implant) J9173 Imfinzi (durvalumab)
J9325 Imlygic (talimogene laherparepvec) Q5103 Inflectra (infliximab-dyyb)
J9198 Infugem (gemcitabine hydrochloride) J9214 Intron-A (interferon alfa-2b)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 8 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J9315 Istodax (romidepsin)
J1556 Bivigam IVIG (Immune Globulin liquid) J1566 Carimune J0850 Cytogam J1572 Flebogamma J1569 Gammagard J1557 Gammaplex J1561 Gamunex J1568 Octagam J1599 Panzyga J1459 Privigen
J1566 IVIG (Immune Globulin powder)
J9207 Ixempra (ixabepilone)
J7195 Ixinity (factor IX recombinant)
J9281 Jelmyto (mitomycin)
J9999/C9399 Jemperli (dostarlimab-gxly)
J7316 Jetrea (ocriplasmin)
J9043 Jevtana (cabazitaxel)
J7208 Jivi (Antihemophilic Factor, Recombinant (pegylated-auci) J9354 Kadcyla (ado-trastuzumab emtansine) J1290 Kalbitor (ecallantide) Q5117 Kanjinti (trastuzumab-anns,
biosimilar) J2840 Kanuma (sebelipase alpha)
J9271 Keytruda (pembrolizumab) J0642 Khapzory (levoleucovorin)
J7190 Koate (Factor VIII)
J7192 Kogenate FS (factor VIII, antihemophilic)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 9 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J7211 Kovaltry (factor VIII, antihemophilic) J2507 Krystexxa (pegloticase)
Q2042 Kymriah (tisagenlecleucel)
J9047 Kyprolis (carfilzomib)
J9285 Lartruvo (olaratumab)
J0202 Lemtrada (alemtuzumab)
J0640 Leucovorin calcium
J2820 Leukine (sargramostim GM-CSF)
J9065 Leustatin (cladribine)
J0641 LEVOleucovorin calcium
J9119 Libtayo (cemiplimab-rwlc)
Q2049 Lipodox (doxorubicin hydrocholoride, liposomal) J2778 Lucentis (ranibizumab Intravitreal) J0221 Lumizyme (alglucosidase alfa)
J9313 Lumoxiti (moxetumomab pasudotox-tdfk) A9513 Lutathera (lutetium lu 177, dotatate, therapeutic) J3398 Luxturna (voretigene neparvovec- rzyl) J2503 Macugen (pegaptanib sodium)
J9999/J9353/C9399 Margenza (margetuximab-cmkb)
J9371 Marqibo (vincristine sulfate liposome) J9245 Melphalan
J3397 Mepsevii (vestronidase alfa-vjbk)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 10 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J9209 Mesna
J9349 Monjuvi (tafasitamab-cxix)
J7190 Monoclate P (antihemophilic factor) J7193 Mononine (Factor IX, antihemophilic factor, purified, non-recombinant) J7327 Monovisc (hyaluronan or derivative) J2562 Mozobil (plerixaflor)
J9280 Mutamycin (mitomycin)
Q5107 Mvasi (bevacizumab-awwb. biosimilar) J9203 Mylotarg (gemtuzumab ozogamicin) J0587 Myobloc (rimabotulinumtoxinB)
J1458 Naglazyme (galsulfase)
J9390 Navelbine (vinorelbine tartrate)
J2505 Neulasta (pegfilgrastim)
J1442 Neupogen (filgrastim)
J9268 Nipent (pentostatin)
Q5110 Nivestym (filgrastim-aafi)
J9293 Novantrone (mitoxantrone)
J7182 Novoeight (factor VIII, antihemophilic factor, recombinant) J7189 Novoseven (antihemophilic factor viia) J2796 Nplate (romiplostim)
J2182 Nucala (mepolizumab)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 11 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J3490/C9399 Nulibry (fosdenopterin)
J0485 Nulojix (belatacept)
J7209 Nuwiq (factor VIII, antihemophilic factor, recombinant) Q5122 Nyvepria (pegfilgrastim-apgf)
J7188 Obizur (antihemophilic factor VIII)
J2350 Ocrevus (ocrelizumab)
Q5114 Ogivri (trastuzumab-dkst, biosimilar) J9266 Oncaspar (pegaspargase)
J9205 Onivyde (irinotecan liposome)
J0222 Onpattro (patisiran)
Q5112 Ontruzant (trastuzumab-dttb)
J9299 Opdivo (nivolumab)
J0129 Orencia (abatacept)
J7324 Orthovisc (hyaluronan or derivative) J0224 Oxlumo (lumasiran)
J7312 Ozurdex (dexamethasone intravitreal implant) J9177 Padcev (enfortumab vedotin-ejfv)
J1599 Panzyga (immune globulin, intravenous) J9045 Paraplatin (carboplatin)
J0606 Parsabiv (etelcalcetide)
J9304 Pemfexy (pemetrexed)
J9247 Pepaxto (melphalan flufenamide hydrochloride) J9306 Perjeta (pertuzumab)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 12 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J9316 Phesgo (pertuzumab, trastuzumab, and hyaluronidase zzxf) J9600 Photofrin (porfimer sodium)
J9060 Platinol (cisplatin)
J9309 Polivy (polatuzumab vedotin-piiq)
J9295 Portrazza (necitumumab)
J9204 Poteligeo (mogamulizumab-kpkc)
J2278 Prialt (ziconotide) Bioscrip
J0570 Probuphine Implant (buprenorphine) J7194 Profilnine/SD (Factor IX, complex) J0256 Prolastin (alpha-1 proteinase Dohmen inhibitor, human) J9015 Proleukin (aldesleukin)
J0897 Prolia (denosumab)
Q2043 Provenge (sipuleucel-T) Contact Manufacturer
J7336 Qutenza (capsaicin patch) Contact Manufacturer
J1301 Radicava (edaravone)
J7203 Rebinyn (factor IX, glycopegylated) J0896 Reblozyl (luspatercept-aamt)
J7192 Recombinate (factor VIII antihemophilic factor) J2212 Relistor (methylnaltrexone)
B4105 Relizorb (digestive enzymes)
J1745 Remicade (infliximab)
J3285 Remodulin (treprostinil)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 13 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies Q5104 Renflexis (infliximab-abda)
Q5106 Retacrit (epoetin alfa-epbx)
J7311 Retisert (fluocinolone acetonide intravitreal implant) J3590/C9399 Revcovi (elapegademase)
Q5123 Riabni (rituximab-arrx)
J7178 RiaSTAP (human fibrinogen concentrate) J9312 Rituxan (rituximab)
J9311 Rituxan Hycela (rituximab/hyaluronidase) J7200 Rixubis (Factor IX)
C9065 Romidepsin
J0596 Ruconest (c-1 esterase inhibitor, recombinant) Q5119 Ruxience (rituximab-pvvr, biosimilar) J9999 Rybrevant (amivantamab-vmjw)
J9999 Rylaze (asparaginase erwinia chrysanthemi (recombinant)- rywn) J2353 Sandostatin LAR (octreotide IM)
J9227 Sarclisa (isatuximab-irfc)
J0604 Sensipar (cinacalcet)
J7212 Sevenfact (Factor viia, Recombinant) J2502 Signifor (pasireotide long acting)
J1602 Simponi ARIA (golimumab)
J1300 Soliris (ecuzliumab)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 14 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J1930 Somatuline Depot (lanreotide)
J3590/C9399 Somavert (pegvisomant)
J2326 Spinraza (nusinersen)
S0013 Spravato (esketamine nasal spray) J3357, J3358 Stelara (ustekinumab)
J7321 Supartz (hyaluronic acid)
J9226 Supprelin LA (histrelin implant)
J1627 Sustol (Granisetron HCl ER)
J2860 Sylvant (siltuximab)
90378 Synagis (palivizumab)
J7331 Synojoynt (hyaluronic acid)
J9262 Synribo (omacetaxine Diplomate mepesuccinate) J7325 Synvisc (3 injection series)
J7325 Synvisc One (1 injection)
J0593 Takhzyro (lanadelumab-flyo)
J9267 Taxol (paclitaxel)
J9171 Taxotere (docetaxel)
Q2053 Tecartus (brexucabtagene autoleucel) J9022 Tecentriq (atezolizumab)
J3490/C9399 Tegsedi (inotersen)
J9328 Temodar Injection (temozolomide) J9340 Tepadina (thiotepa)
J3241 Tepezza (teprotumumab-trbw)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 15 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J3490/S0189 Testopel (testosterone implant) Walgreens
J3240 Thyrogen (thyrotropin alpha)
J9030 Tice BCG (BCG live intravesical instillation) J9181 Toposar (etoposide)
J9330 Torisel (temsirolimus)
Q5116 Trazimera (trastuzumab-qyyp)
J9033 Treanda (bendamustine HCl)
J3315 Trelstar (triptorelin pamoate)
J1628 Tremfya (guselkumab)
J7181 Tretten (Factor XIII A-subunit)
J7332 Triluron (hyaluronic acid)
J9017 Trisenox (arsenic trioxide)
J7329 TriVisc (hyaluronic acid)
J9317 Trodelvy (sacituzumab govitecan- hziy) J1746 Trogarzo (ibalizumab-uiyk)
Q5115 Truxima (rituximab-abbs)
J2323 Tysabri (natalizumab)
J7686 Tyvaso (treprostinil inh)
Q5111 Udenyca (pegfilgrastim-cbqv)
J1303 Ultomiris (ravulizumab)
J9999/C9399 Unituxin (dinutuximab)
J1823 Uplizna (inebilizumab-cdon)
J9357 Valstar (valrubicin, intravesical)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 16 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J9225 Vantas (histrelin implant)
J9303 Vectibix (panitumumab)
J9360 Velban (vinblastine)
J9041/J9044 Velcade (bortezomib)
Q4074 Ventavis (iloprost inhalation)
J9025 Vidaza (azacitidine)
J1427 Viltepso (viltolarsen)
J1322 Vimizim (elosulfase alfa)
J9370 Vincasar (vincristine sulfate)
J7321 Visco-3 (sodium hyaluronate)
J7179 Vonvendi (Von Willebrand Factor)
J3385 Vpriv (velaglucerase alfa)
Q2017 Vumon (teniposide)
J3032 Vyepti (eptinezumab-jjmr)
J1429 Vyondys 53 (golodirsen)
J9153 Vyxeos (daunorubicin/cytarabine)
J7183 Wilate (Von Willebrand factor complex, human) J3490/C9399 Xaracoll (bupivacaine hydrochloride) Implant J1558 Xembify (Immune globulin, human-klhw) J0588 Xeomin (incobotulinumtoxinA)
J0775 Xiaflex (collagenase, clostridium histolyticum) A9606 Xofigo (Radium Ra-223 Nuclear Medicine and Dichloride) Hospital Clinics
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 17 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY
Drug Name Limited distribution Code (Brand/Generic) Pharmacies J2357 Xolair (omalizumab)
J7185 Xyntha (Factor VIII)
J9228 Yervoy (ipilimumab)
Q2041 Yescarta (Axicabtagene ciloleucel) J9352 Yondelis (trabectedin)
J7314 Yutiq (fluocinolone intravitreal)
J9400 Zaltrap (ziv-aflibercept)
J9320 Zanosar (streptozocin)
Q5101 Zarxio (filgrastim-sndz, biosimilar)
J0256 Zemaira (alpha1-proteinase inhibitor) J9223 Zepzelca (lurbinectedin)
A9543 Zevalin (ibritumomab tiuxetan) Nuclear Medicine and Hospital Clinics Q5120 Ziextenzo (pegfilgrastim-bmez)
J3304 Zilretta (triamcinolone acetonide)
J0565 Zinplava (bezlotoxumab)
Q5118 Zirabev (bevacizumab-bvzr)
J9202 Zoladex (Goserelin acetate implant) J3399 Zolgensma (onasemnogene abeparvovec-xioi) J1632 Zulresso (brexanolone)
J9999/C9399 Zynlonta (loncastuximab tesirine- lpyl)
Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 18 of 18 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx