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Together with CCHP's Medication List Prior Authorization Is Required If Indicated by X(PA)

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Together with CCHP's Medication List Prior Authorization Is Required If Indicated by X(PA) Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes J3365 Abbokinase INJECTION, UROKINASE, 250,000 IU X J0287 Abelcet INJECTION, AMPHOTERICIN B LIPID X COMPLEX, 10 MG J0401 Abilify Maintena INJECTION, ARIPIPRAZOLE, EXTENDED X X May bIll eIther RELEASE, 1 MG (PA < 12 YEARS OF benefIt, PA AGE) reQuIred when bIllIng through pharmacy INJECTION, PACLITAXEL PROTEIN- J9264 Abraxane BOUND PARTICLES, 1 MG X J7613 Accuneb ALBUTEROL, INHALATION SOLUTION, X FDA- APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG J0132 Acetadote INJECTION, ACETYLCYSTEINE, 100 MG X J7608 Acetylcysteine ACETYLCYSTEINE, INHALATION X SOLUTION, FDA- APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER G J3262 Actemra INJECTION, TOCILIZUMAB, 1 MG X (PA) J0800 Acthar Gel INJECTION, CORTICOTROPIN, UP TO 40 X (PA) UNITS J0795 Acthrel INJECTION, CORTICORELIN OVINE X TRIFLUTATE, 1 MCG J9216 Actimmune INTERFERON GAMMAM 1-B X (PA) J2997 Activase INJECTION, ALTEPLASE RECOMBINANT, X 1 MG J2504 Adagen PEGADEMASE BOVINE 25 IU X (PA) J2062 Adasuve LoxapIne, InhalatIon powder, 10 mg X INJECTION, BRENTUXIMAB VEDOTIN, 1 J9042 Adcetris X MG 1 Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes J0151 Adenoscan INJECTION, ADENOSINE FOR X DIAGNOSTIC USE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS,INSTEAD USE A9270) J0152 Adenoscan INJECTION, ADENOSINE FOR X DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9270) J0153 Adenoscan INJECTION, ADENOSINE, 1 MG (NOT TO X BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS) J9000 Adriamycin INJECTION, DOXORUBICIN HCL, 10 MG X J9190 Adrucil INJECTION, FLUOROURACIL, 500 MG X J7207 Adynovate INJECTION FACTOR VIII PEGYLATED 1 X Q2035 Afluria VACCINE,I.U. IM X X May bIll either benefIt C9140 Afstyla InjectIon, Factor VIII 1 I.U. X J7210 Afstyla INJECTION, FACTOR VIII X (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (AFSTYLA) 1 IU J3246 Aggrastat INJECTION, TIROFIBAN HCL, 0.25MG X J1454 Akynzeo InjectIon, fosnetupitant 235 mg and X palonosetron 0.25 mg J8655 Akynzeo NETUPITNT 300 MG&PALONOSETRN X 0.5 MG Q9978 Akynzeo inj NETUPITANT 300 MG AND X (PA) PALONOSETRON 0.5 MG J1931 Aldurazyme INJECTION, LARONIDASE X (PA) J9215 Alferon- N INJECTION, ALFA N3 X interferon J9305 Alimta INJECTION, PEMETREXED, 10 MG X J9057 Aliqopa injection copanlisib 1 mg X J8600 Alkeran MELPHALAN, ORAL, 2 MG X 2 Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes INJECTION, MELPHALAN HYDROCHL, J9245 Alkeran X 50MG J2469 Aloxi INJECTION, PALONOSETRON HCL, 25 X MCG J7193 Alphanine FACTOR IX NON- RECOMBINANT, 1 IU X J7201 Alprolix INJECTION, FACTOR IX, FC FUSION X PROTEIN (RECOMBINANT), PER IU J0289 Ambisome INJECTION, AMPHOTERICIN B X LIPOSOME, 10MG J7345 AMINOLEVULINIC ACID HCL FOR X Ameluz TOPICAL ADMINISTRATION, 10%, J0215 Amevive ALEFACEPT X J3470 Amphadase INJECTION, HYALURONIDASE, UP TO X 150 UNITS J0288 Amphotec INJECTION, AMPHO B CHOLESTERYL X SULFATE, 10MG J0716 Anascorp INJECTION, CENTRUROIDES IMMUNE X F(AB)2, UP TO 120 MG J0583 Angiomax INJECTION, BIVALIRUDIN, 1 MG X J1451 Antizol INJECTION, FOMEPIZOLE, 15 MG X J1260 Anzemet INJECTION, DOLASETRON MESYLATE, X 10 MG S0174 Anzemet DOLASETRON MESYLATE , ORAL 50 MG X (FOR CIRCUMSTANCES FALLING UNDER MEDICARE STATUTE) J0364 Apokyn INJECTION, APOMORPHINE X (PA) HYDROCHLORIDE 1 MG J0256 Aralast NP, INJECTION, ALPHA 1-PROTEINASE X (PA) Prolastin, INHIBITOR (HUMAN), NOT OTHERWISE Prolastin C, SPECIFIED, 10 MG Zemaira J0881 Aranesp INJECTION, DARBEPOETIN ALFA, 1 MCG X (PA) X May bIll eIther (NON-ESRD USE) benefIt, PA reQuIred when bIllIng through pharmacy 3 Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes J0882 Aranesp INJECTION, DARBEPOETIN ALFA, 1 MCG X (PA) X May bIll eIther (FOR ESRD ON DIALYSIS) benefIt, PA reQuIred when bIllIng through pharmacy J2793 Arcalyst INJECTION, RILONACEPT X (PA) J2430 Aredia INJECTION, PAMIDRONATE DISODIUM, X PER 30 MG J7605 Arformoterol ARFORMOTEROL, INHALATION X SOLUTION, FDA APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MCG J0883 Argatroban INJECTION, ARGATROBAN 1MG NON X ESRD USE J0884 Argatroban INJECTION, ARGATROBAN 1MG ESRD X ON DIALYSIS J7665 Aridol MANNITOL, ADMINISTERED THRU AN X INHALER, 5 MG S0170 Arimidex ANASTRAZOLE, ORAL, 1 MG X J1942 Aristada INJECTION, ARIPIPRAZOLE LAUROXIL X X May bIll eIther 1MG (PA < 12 YEARS OF benefIt, PA AGE) reQuIred when bIllIng through pharmacy C9035 Aristada Initio InjectIon, arIpiprazole lauroxIl X X May bIll eIther (arIstada InItIo), 1 mg (PA < 12 YEARS OF benefIt, PA AGE) reQuIred when bIllIng through pharmacy J3303 Aristospan INJECTION, TRIAMCINOLONE X HEXACETONIDE, PER 5 MG J1652 Arixtra INJECTION, FONDAPARINUX SODIUM, X X May bIll 0.5 MG either benefIt S0156 Aromasin EXEMESTANE, 25 MG X 4 Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes J9261 Arranon INJECTION, NELARBINE, 50 MG X C9250 Artiss artIss fIbrIn sealant X J9302 Arzerra INJECTION, OFATUMUMAB, 10 MG X TACROLIMUS, EXTENDED RELEASE, J7508 Astagraf XL X ORAL, 0.1 MG J2275 Astramorph INJECTION, MORPHINE SULFATE X (PRESERVATIVE- FREE STERILE SOLUTION), PER 10 MG J7504 Atgam INJECTION LYMPHOCYTE IMMUNE X GLOBULIN, 250MG J2060 Ativan INJECTION, LORAZEPAM, 2 MG X J9035 Avastin INJECTION, BEVACIZUMAB, 10 MG X J3145 Aveed INJECTION, TESTOSTERONE X (PA) UNDECANOATE, 1 MG J2280 Avelox INJECTION, MOXIFLOXACIN, 100 MG X J1825 Avonex INJECTION, INTERFERON BETA 1 A, 11 X MCGS FOR IM USE Q3027 Avonex INJECTION, INTERFERON BETA-1A, 1 X MCG, FOR INTRAMUSCULAR USE J0714 Avycaz INJ CFTAZDM & AVIBCTM 0.5 G/0.125 X C9408 Azedra IodineG I-131 Iobenguane, therapeutIc, X (PA) 1 mIllIcurIe J0470 Bal in Oil INJECTION, DIMECAPROL 100MG X J9023 Bavencio INJECTION, AVELUMAB, 10 MG X C9462 Baxdela InjectIon, delafloxacIn, 1 mg X J7194 Bebulin, FACTOR IX COMPLEX, 1 IU X Profilnine J9032 Beleodaq INJECTION BELINOSTAT 10 MG X J1200 Benadryl INJECTION, DIPHENHYDRAMINE HCL, X UP TO 50 MG J9034 Bendeka INJECTION, BENDAMUSTINE HCL, 1 MG X J7195 Benefix FACTOR IX RECOMBINANT, 1IU X J0490 Benlysta INJECTION, BELIMUMAB, 10 MG X (PA) J0500 Bentyl INJECTION, DICYCLOMINE HCL, UP TO X 20 MG 5 Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes J0597 Berinert INJECTION, C-1 ESTERASE INHIBITOR X (PA) (HUMAN), BERINERT, 10 UNITS InjectIon, Inotuzumab ozogamIcIn, J9229 Besponsa X 0.1 mg INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN Betaseron/ DRUG ADMINISTERED UNDER THE J1830 X (PA) Extavia DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF- ADMINISTERED) J0558 Bicillin C-R INJECTION, PENICILLIN G BENZATHINE X AND PENICILLIN G PROCAINE, 100,000 UNITS J0561 Bicillin L-A INJECTION, PENICILLIN G BENZATHINE, X 100,000 UNITS J9050 BICNU INJECTION, CARMUSTINE, 100MG X J1556 Bivigam INJECTION, IMMUNE GLOBULIN X (PA) (BIVIGAM), 500 MG INJECTION, BLINATUMOMAB 1 J9039 Blincyto X MICROGRAM ThIs Jcode Is shared by two different dosage forms (both are ibandronate). Both INJECTION, IBANDRONATE SODIUM, 1 products can be J1740 Boniva X X MG billed vIa jcode (no PA reQuIred). Ibandronate vIal Is not covered on the pharmacy benefIt. J0585 Botox INJECTION, ONABOTULINUMTOXINA, 1 X (PA) UNIT J3355 Bravelle INJECTION, UROFOLLITROPIN, 75 IU X J0567 Brineura INJ CERLIPONASE ALFA, 1 MG X (PA) 6 Together with CCHP's Medication List Prior authorization is required if indicated by X(PA). Pharmacy Benefit: Submit authorizations through Together with CCHP's Pharmacy Services. Medical Benefit: Submit authorizations through CareWeb Qi Authorization tool. Jcode Brand Name Description Pharmacy Medical Notes J9010 Campath INJECTION, ALEMTUZUMAB, 10 MG X J9206 Camptosar INJECTION, IRINOTECAN, 20 MG X J0637 Canidas INJECTION, CASPOFUNGIN ACETATE, 5 X MG J1955 Carnitor INJECTION, LEVOCARNITINE, PER 1 G X J7330 Carticel IMPLANT, CULTURED CHONDROCYTES, X 1 EA J0270 Caverject, Edex PROSTAGLANDIN E1,IC X S0178 Ceenu LOMUSTINE, ORAL, 10 MG X J0702 Celestone INJECTION, BETAMETHASONE ACETATE X Soluspan 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG
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