July 1, 2020 RE: Physician Administered Drugs (J Codes)

July 1, 2020

RE: Physician Administered Drugs (J Codes) Included in Prior Authorization Matrix for Molina Healthcare of New York, Inc.

Dear Participating Provider:

Molina Healthcare of New York, Inc. requires prior authorization for these HCPCS codes for all participating providers. Prior authorization is required before services are rendered for the codes listed.

Prior authorization requests should include the most up to date patient information including office notes, consultations, labs, scans, previous treatments tried, and any other patient specific information to support the request. Please fax a completed prior authorization form along with all supporting clinical documentation to fax number: 1-844- 823-5479. Our prior authorization form and most up to date formulary can be found on our website: MolinaHealthcare.com.

C9061 INJECTION, TEPROTUMUMAB-TRBW, 10 mg C9063 INJECTION, EPTINEZUMAB-JJMR, 1 mg C9122 MOMETASONE FUROATE SINUS IMPLANT, 10 micrograms (sinuva) J0122 INJECTION, ERAVACYCLINE, 1 mg J0129 Injection, abatacept 10 mg J0178 Injection, aflibercept 1 mg J0179 INJECTION, BROLUCIZUMAB-DBLL, 1MG J0185 Injection, aprepitant 1 mg J0223 INJECTION, GIVOSIRAN, 0.5 mg J0285 INJECTION, AMPHOTERICIN B, 50 mg J0490 Injection, belimumab 10 mg J0517 Injection, benralizumab 1 mg J0567 Injection, cerliponase alfa 1 mg J0584 Injection, burosumab-twza 1 mg J0585 Injection, onabotulinumtoxina, 1 unit J0587 Injection, rimabotulinumtoxinb 100 units J0599 Injection, c-1 esterase inhibitor 10 units J0641 Injection, levoleucovorin, not otherwise specified, 0.5 mg J0642 INJECTION LEVOLEUCOVORIN (KHAPZORY), 0.5 mg J0691 INJECTION, LEFAMULIN, 1 mg J0740 Injection, cidofovir, 375 mg J0791 INJECTION, CRIZANLIZUMAB-TMCA, 5 mg

J0881 Injection, darbepoetin alfa, 1 microgram (non-esrd use) J0887 Injection, epoetin beta, 1 microgram, (for esrd on dialysis) J0896 INJECTION, LUPATERCEPT-AAMT, 0.25 mg J0897 Injection, denosumab 1 mg J1301 Injection, edaravone 1 mg J1429 INJECTION, GOLODIRSEN, 10 mg J1447 Injection, tbo-filgrastim 1 microgram J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg J1459 Injection, immune globulin, (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg J1558 INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 mg J1561 Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg J1569 Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (liquid), J1572 500 mg J1602 Injection, golimumab, 1 mg, for intravenous use J1628 Injection, guselkumab, 1 mg J1745 Injection infliximab excludes biosimilar 10 mg J1746 Injection, ibalizumab-uiyk 10 mg J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg J2323 Injection, natalizumab 1 mg J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg J2357 Injection, omalizumab 5 mg J2505 Injection, pegfilgrastim 6 mg J2770 INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 mg (150/350) J2778 Injection, ranibizumab 0.1 mg J2796 Injection, romiplostim 10 mcg J2797 Injection, rolapitant 0.5 mg J3245 Injection, tildrakizumab 1 mg J3262 Injection, tocilizumab 1 mg J3304 Injection, triamcinolone acetonide, preservative-free, ER, microsphere formulation, 1 mg J3316 Injection, triptorelin, extended release, 3.75 mg J3380 Injection, vedolizumab 1 mg J3396 Injection, verteporfin 0.1 mg J3397 Injection, vestronidase alfa-vjbk 1 mg J3398 Injection, voretigene neparvovec-rzyl 1 b vec g J3399 INJECTION, ONASEMNOGENE ABEPARVOVEC, PER TX, UP TO 5x10^15 VECTOR GENOMES J3591 Unclassified drug or biological used for esrd on dialysis J7175 Injection, factor x, (human), 1 i.u. J7179 Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco

J7180 Injection, factor xiii (antihemophilic factor, human), 1 i.u. J7181 Injection, factor xiii a-subunit, (recombinant), per iu J7182 Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu J7185 Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. J7186 Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. J7187 Injection, von willebrand factor complex (humate-p), per iu vwf:rco J7188 Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. J7189 Factor viia (antihemophilic factor, recombinant), per 1 microgram J7190 Factor viii (antihemophilic factor, human) per i.u. J7191 Factor viii (antihemophilic factor (porcine)), per i.u. J7192 Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified J7193 Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. J7194 Factor ix, complex, per i.u. J7195 Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified J7197 Antithrombin iii (human), per i.u. J7198 Anti-inhibitor, per i.u. J7199 Hemophilia clotting factor, not otherwise classified J7200 Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu J7201 Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. J7202 Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. INJECTION, FACTOR VIII, ATHIHEMPHILIC FACTOR (RECOMBINANT), (ESPEROCT), J7204 GLYCOPEGYLATED-EXEI, PER IU J7205 Injection, factor viii fc fusion protein (recombinant), per iu J7207 Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. J7209 Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. J7331 Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg J7332 Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg J7333 HYALURONAN OR DERIVATIVE, VISCO-3, FOR INTRA-ARTICULAR INJ, PER DOSE J7336 CAPSAICIN 8% PATCH, PER SQ CENTIMETER J7401 Mometasone furoate sinus implant 10 mcg J7999 Compounded drug, not otherwise classified J8498 Antiemetic drug, rectal/suppository, not otherwise specified J8597 Antiemetic drug, oral, not otherwise specified J8999 Prescription drug, oral, chemotherapeutic, not otherwise specified J9030 Bcg live intravesical instillation 1 mg J9033 Injection, bendamustine hcl (treanda), 1 mg J9035 Injection bevacizumab 10 mg J9041 Injection bortezomib 0.1 mg J9044 Injection, bortezomib, not otherwise specified, 0.1 mg

J9055 Injection cetuximab 10 mg J9057 Injection copanlisib 1 mg J9070 Cyclophosphamide 100 mg J9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine J9155 Injection degarelix 1 mg J9171 Injection docetaxel 1 mg J9173 Injection durvalumab 10 mg J9177 INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 mg J9198 INJECTION, GEMCITABINE HYDROCHLORIDE (infugem), 100 mg J9199 INJECTION, GEMCITABINE HYDROCHLORIDE (infugem), 200 MG J9217 Leuprolide acetate (for depot suspension), 7.5 mg J9226 Histrelin implant supprelin la 50 mg J9229 Injection inotuzumab ozogamicin 0.1 mg J9246 INJECTION, MELPHALAN (evomela), 1 mg J9263 Injection oxaliplatin 0.5 mg J9264 Injection paclitaxel proteinbound particles 1 mg J9271 Injection pembrolizumab 1 mg J9299 Injection nivolumab 1 mg J9305 Injection pemetrexed 10 mg J9306 Injection pertuzumab 1 mg J9308 Injection ramucirumab 5 mg J9309 INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG J9311 Injection rituximab 10 mg and hyaluronidase J9312 Injection rituximab 10 mg J9354 Injection, ado-trastuzumab emtansine, 1 mg J9355 Injection, trastuzumab, excludes biosimilar, 10 mg J9358 INJECTION, FAM-TRASTUZUMAB DERUXTECAN-NXKI, 1 mg J9999 Not otherwise classified antineoplastic drug Q5101 Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram Q5103 Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg Q5104 Injection, infliximab-abda, biosimilar, (renflexis), 10 mg Q5105 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units Q5106 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units Q5108 Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg Q5110 Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram Q5111 Injection, pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg Q5116 Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg

Q5118 Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg Q5119 INJECTION, RITUXIMAB-PVVR, BIOSIMILAR, (ruxience), 10 mg Q5120 INJECTION, PEGFILGRASTIM-BMEZ, BIOSIMILAR, (ziextenzo), 0.5 mg Q5121 IJNECTION, INFLIXIMAB-AXXQ, BIOSIMILAR, (avsola), 10 mg Q9991 Injection, buprenorphine extended release (sublocade), less than or equal to 100 mg Q9992 Injection, buprenorphine extended release (sublocade), greater than 100 mg

Thank you for your understanding and cooperation. �

Sincerely, �

Jacqueline Jacobi, Pharmacist � Regional Director of Pharmacy �