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Appendix B. Drug Codes Requiring Authorization the Following Codes Will Require Authorization for MA Effective Oct 1, 2017 Page

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Appendix B. Drug Codes Requiring Authorization the Following Codes Will Require Authorization for MA Effective Oct 1, 2017 Page Appendix B. Drug Codes Requiring Authorization The following codes will require authorization for MA effective Oct 1, 2017 Code Description Code Description 90585 BCG VACCINE, PERCUT J1458 GALSULFASE INJECTION 90586 HEP A VACCINE, ADULT IM J1459 INJ IVIG PRIVIGEN 500 MG 90691 TYPHOID VACCINE, IM J1460 GAMMA GLOBULIN 1 CC INJ J0129 ABATACEPT INJECTION J1556 INJ, IMM GLOB BIVIGAM, 500 MG J0135 ADALIMUMAB INJECTION J1557 GAMMAPLEX INJECTION J0178 AFLIBERCEPT INJECTION J1559 HIZENTRA INJECTION J0180 AGALSIDASE BETA INJECTION J1560 GAMMA GLOBULIN > 10 CC INJ J0207 AMIFOSTINE J1561 INJECTION IMMUNE GLOB IV 500 M J0215 ALEFACEPT J1566 IMMUNE GLOBULIN, POWDER J0220 ALGLUCOSIDASE ALFA INJECTION J1568 OCTAGAM INJECTION J0221 LUMIZYME INJECTION J1569 Gammagard Liquid Injection J0256 ALPHA 1 PROTEINASE INHIBITOR J1570 GANCICLOVIR SODIUM INJECTION J0257 GLASSIA INJECTION J1571 HEPAGAM B IM INJECTION J0400 INJ TRIMETHAPHAN CAMSYLATE J1572 FLEBOGAMMA INJECTION J0401 INJ ARIPIPRAZOLE EXT REL 1MG J1602 Inj, golimumab for IV use 1 mg J0480 BASILIXIMAB J1640 HEMIN, 1 MG J0485 BELATACEPT INJECTION J1745 INFLIXIMAB INJECTION J0490 BELIMUMAB INJECTION J1786 IMUGLUCERASE INJECTION J0585 BOTULINUM TOXIN A PER UNIT J1930 PROPIOMAZINE INJECTION J0586 ABOBOTULINUMTOXINA J1931 LARONIDASE INJECTION J0587 BOTULINUM TOXIN TYPE B J1950 LEUPROLIDE ACETATE /3.75 MG J0588 INCOBOTULINUMTOXIN A J1955 INJ LEVOCARNITINE PER 1 GM J0594 BUSULFAN INJECTION J2260 INJ MILRINONE LACTATE / 5 MG J0638 CANAKINUMAB INJECTION J2278 ZICONOTIDE INJECTION J0640 LEUCOVORIN CALCIUM INJECTION J2323 NATALIZUMAB INJECTION J0641 LEVOLEUCOVORIN INJECTION J2353 OCTREOTIDE INJECTION, DEPOT J0670 INJ MEPIVACAINE HCL/10 ML J2354 OCTREOTIDE INJ, NON‐DEPOT J0717 CERTOLIZUMAB PEGOL INJ 1MG J2355 OPRELVEKIN INJECTION J0886 EPOETIN ALFA, ESRD J2357 OMALIZUMAB INJECTION J0894 DECITABINE INJECTION J2425 PALIFERMIN INJECTION J0895 Deferoxamine mesylate inj J2430 PAMIDRONATE DISODIUM /30 MG J0897 INJECTION DENOSUMAB J2469 PALONOSETRON HCL J1162 digoxin immune fab J2501 PARICALCITOL J1300 ECULIZUMAB INJECTION J2503 PEGAPTANIB SODIUM INJECTION J1325 EPOPROSTENOL INJECTION J2504 PEGADEMASE BOVINE, 25 IU J1442 INJ, FILGRASTIM G‐CSF 1 MCG J2505 INJECTION, PEGFILGRASTIM 6MG J1446 INJ, TBO‐FILGRASTIM, 5 MCG J2507 PEGLOTICASE INJECTION J1453 FOSAPREPITANT INJECTION J2545 PENTAMIDINE ISETHIONTE/300MG Page 1 of 3 Appendix B. Drug Codes Requiring Authorization The following codes will require authorization for MA effective Oct 1, 2017 Code Description Code Description J2562 PLERIXAFOR INJECTION J7639 DORNASE ALPHA INHAL SOL U D J2724 PROTEIN C CONCENTRATE J7686 TREPROSTINIL, NON‐COMP UNIT J2760 PHENTOLAINE MESYLATE INJ J8501 ORAL APREPITANT J2778 RANIBIZUMAB INJECTION J8510 ORAL BUSULFAN J2783 RASBURICASE J8520 CAPECITABINE, ORAL, 150 MG J2796 ROMIPLOSTIM INJECTION J8521 CAPECITABINE, ORAL, 500 MG J2820 SARGRAMOSTIM INJECTION J8530 CYCLOPHOSPHAMIDE ORAL 25 MG J3060 INJ, TALIGLUCERACE ALFA 10 UNI J8560 ETOPOSIDE ORAL 50 MG J3262 TOCILIZUMAB INJECTION J8600 MELPHALAN ORAL 2 MG J3285 TREPROSTINIL INJECTION J8610 METHOTREXATE ORAL 2.5 MG J3315 TRIPTORELIN PAMOATE J8700 TEMOZOLOMIDE J3357 USTEKINUMAB INJECTION J8705 TOPOTECAN ORAL J3385 VELAGLUCERASE ALFA J9000 DOXORUBIC HCL 10 MG VL CHEMO J3590 UNCLASSIFIED BIOLOGICS J9015 ALDESLEUKIN/SINGLE USE VIAL J7180 FACTOR XIII ANTI‐HEM FACTOR J9017 ARSENIC TRIOXIDE J7183 WILATE INJECTION J9019 ERWINAZE INJECTION J7185 XYNTHA INJ J9020 ASPARAGINASE INJECTION J7186 ANTIHEMOPHILIC VIII/VWF COMP J9025 AZACITIDINE INJECTION J7187 INJ VONWILLEBRAND FACTOR IU J9027 CLOFARABINE INJECTION J7189 FACTOR VIIA J9031 BCG LIVE INTRAVESICAL VAC J7190 FACTOR VIII J9033 BENDAMUSTINE INJECTION J7192 FACTOR VIII RECOMBINANT J9035 BEVACIZUMAB INJECTION J7193 FACTOR IX NON‐RECOMBINANT J9040 BLEOMYCIN SULFATE INJECTION J7194 FACTOR IX COMPLEX J9041 BORTEZOMIB INJECTION J7195 FACTOR IX RECOMBINANT J9042 BRENTUXIMAB VEDOTIN INJ J7197 ANTITHROMBIN III INJECTION J9043 CABAZITAXEL INJECTION J7198 ANTI‐INHIBITOR J9045 CARBOPLATIN INJECTION J7308 AMINOLEVULINIC ACID HCL TOP J9047 INJECTION, CARFILZOMIB, 1 MG J7312 DEXAMETHASONE INTRA IMPLANT J9050 CARMUS BISCHL NITRO INJ J7316 SODIM HYALURONATE 5 MG ARTICLR J9055 CETUXIMAB INJECTION J7321 HYALGAN/SUPARTZ INJ PER DOSE J9060 CISPLATIN 10 MG INJECTION J7323 EUFLEXXA INJ PER DOSE J9065 INJ CLADRIBINE PER 1 MG J7324 ORTHOVISC INJ PER DOSE J9070 CYCLOPHOSPHAMIDE 100 MG INJ J7325 SYNVISC OR SYNVISC‐ONE J9098 CYTARABINE LIPOSOME J7326 GEL‐ONE J9100 CYTARABINE HCL 100 MG INJ J7504 LYMPHOCYTE IMMUNE GLOBULIN J9120 DACTINOMYCIN ACTINOMYCIN D J7511 ANTITHYMOCYTE GLOBULN RABBIT J9130 DACARBAZINE 100 MG INJ J7608 ACETYLCYSTEINE INH SOL U D J9150 DAUNORUBICIN Page 2 of 3 Appendix B. Drug Codes Requiring Authorization The following codes will require authorization for MA effective Oct 1, 2017 Code Description Code Description J9155 DEGARELIX INJECTION J9320 STREPTOZOCIN INJECTION J9171 DOCETAXEL INJECTION J9328 TEMOZOLOMIDE INJECTION J9178 INJ, EPIRUBICIN HCL, 2 MG J9330 TEMSIROLIMUS INJECTION J9179 ERIBULIN MESYLATE INJECTION J9351 TOPOTECAN INJECTION J9181 ETOPOSIDE 10 MG INJ J9354 INJ, ADO‐TRASTUZUMAB EMT 1 MG J9185 FLUDARABINE PHOSPHATE INJ J9355 TRASTUZUMAB J9190 FLUOROURACIL INJECTION J9357 VALRUBICIN, 200 MG J9200 FLOXURIDINE INJECTION J9360 VINBLASTINE SULFATE INJ J9201 GEMCITABINE HCL J9370 VINCRISTINE SULFATE 1 MG INJ J9202 GOSERELIN ACETATE IMPLANT J9371 INJ, VINCRISTINE SUL LIP 1 MG J9208 IFOSFOMIDE INJECTION J9390 VINORELBINE TARTRATE/10 MG J9209 MESNA INJECTION J9395 INJECTION, FULVESTRANT J9211 IDARUBICIN HCL INJECTION J9400 INJ, ZIV‐AFLIBERCEPT, 1 MG J9214 INTERFERON ALFA‐2B INJ Q0138 INJ,FERUMOXYTOL 1MG (NON‐ESRD) J9217 LEUPROLIDE ACETATE SUSPNSION Q0139 INJ,FERUMOXYTOL 1MG‐ESRD/DIALY J9218 LEUPROLIDE ACETATE INJECITON Q2043 SIPULEUCEL‐T AUTO CD54+ J9225 HISTRELIN IMPLANT Q2049 IMPORTED LIPODOX INJ J9226 SUPPRELIN LA IMPLANT Q2050 DOXORUBICIN HYDROCHLORIDE 10MG J9228 IPILIMUMAB INJECTION Q4081 EPOETIN ALFA, 100 UNITS ESRD J9230 MECHLORETHAMINE HCL INJ Q4101 APLIGRAF SKIN SUB J9245 INJ MELPHALAN HYDROCHL 50 MG Q4102 OASIS WOUND MATRIX SKIN SUB J9250 METHOTREXATE SODIUM INJ Q4104 INTEGRA BMWD SKIN SUB J9260 METHOTREXATE SODIUM INJ Q4105 INTEGRA DRT SKIN SUB J9261 NELARABINE INJECTION Q4106 DERMAGRAFT SKIN SUB J9263 OXALIPLATIN Q4107 GRAFTJACKET SKIN SUB J9264 PACLITAXEL INJECTION Q4108 INTEGRA MATRIX SKIN SUB J9265 PACLITAXEL INJECTION Q4110 PRIMATRIX SKIN SUB J9266 PEGASPARGASE/SINGL DOSE VIAL Q4111 GAMMAGRAFT SKIN SUB J9268 PENTOSTATIN INJECTION Q4112 CYMETRA ALLOGRAFT J9280 MITOMYCIN 5 MG INJ Q4113 GRAFTJACKET EXPRESS ALLOGRAF J9293 MITOXANTRONE HYDROCHL / 5 MG Q4114 INTEGRA FLOWABLE WOUND MATRI J9302 OFATUMUMAB INJECTION Q4115 ALLOSKIN SKIN SUB J9303 PANITUMUMAB INJECTION Q4116 ALLODERM SKIN SUB J9305 PEMETREXED INJECTION Q4121 THERASKIN J9306 INJECTION, PERTUZUMAB, 1 MG Q4123 ALLOSKIN J9307 PRALATREXATE INJECTION Q4131 EPIFIX J9310 RITUXIMAB CANCER TREATMENT J9315 ROMIDEPSIN INJECTION Page 3 of 3 .
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