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Home , Burosumab, Eteplirsen, Taliglucerase alfa

PHPprime Prior Authorization Drug List

Medicare Part B KDL 1/22/2021 This is the prior authorization drug list for the UnitedHealthcare AARP Medicare Advantage plan, effective July 1, 2021.

GENERIC NAME TRADE NAME(S) JCODE(S) Step Therapy Voretigene Neparvovec-rzy N/A J3398 Abatacept Orencia J0129 AbobotulinumtoxintypeA Botox J0586 Adalimumab Humira J0135 Afamelanotide implant Scenesse J7352 Alefacept Amevive J0215 Alemtuzumab Campath J0202 Ceredase J0205 Alpha 1 Proteinase Inhibitor Aralast NP J0256, J0257 Anti-inhibitor N/A J7198 Asceniv N/A J1554 Belatacept Nulojix J0485 Belimumab Benlysta J0490 Benralizumab Fasenra J0517 * *Compound Avastin J9035 Yes (* for ARMD Only) Bevacizumab* *Compound Avastin C9257 Yes (* for ARMD Only) Bevacizumab* Eylea J0178 Yes Bevacizumab* Beovu J0179 Yes Bevacizumab* Macugen J2503 Yes Bevacizumab* Lucentis J2778 Yes Brexucabtagene autoleucel, Brexucabtagene Tecartus C9073 autoleucel, up to 200 million autologous anti- cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose, including leukapheresis and dose preparation procedures, per therapeutic dose

Burosumab-twza N/A J0584 C-1 Esterase Inhibitor Berinert J0597 C-1 Esterase Inhibitor Protein Cinryze J0598 C-1 Esterase Inhibitor Protein Ruconest J0596 Certolizumab Pegol Cimzia J0717 Corticotropin Acthar Gel, H.P., Acthar, Acthar Gel, J0800 H.P., ACTH Gel Crizanlizumab-tmca Adekveo J0791, C9053 Darbepoetin * Aranesp J0881, J0882 Yes Decitabine Dacogen, Decitabine Novaplus J0894 Prolia, Xgeva J0897 Dexrazoxane Totect, Zinecard J1190 Eculizumab Soliris J1300 Edaravone Radicava J1301 Epoetin alfa, ersd on dialysis Epogen/Procrit J0886 Epoetin alfa, non-ersd * Epogen/Procrit J0885 Yes Epoetin beta, esrd on dialysis Epogen/Procrit J0887 Epoetin beta, non-esrd Epogen/Procrit J0888 -jjmr Vyepti J3032 Esketamine Spravato S0013 Etanercept Enbrel J1438 Eteplirsen Exondys J1428 Factor ix (antihemophilic factor, purified, N/A J7193 non-recombinant) Factor IX, (antihemophilic factor, Rixubis J7200 recombinant) Factor ix, complex N/A J7194 Factor IX, Fc fusion protein, (recombinant) Alprolix J7201 Factor viia (antihemophilic factor, N/A J7189 recombinant) Factor viia (antihemophilic factor, Sevenfact J7212 recombinant)-jncw Factor viii (antihemophilic factor) Porcine J7191 Factor viii (antihemophilic factor, human) N/A J7190 Factor viii (antihemophilic factor, Obizur J7188 recombinant) Factor viii (antihemophilic factor, Xyntha J7185 recombinant) Factor viii (antihemophilic factor, N/A J7192 recombinant), not otherwise specified Factor VIII Fc fusion protein (recombinant) N/A J7205 Factor VIII, (antihemophilic factor, Afstyla, Kovaltry J7210, J7211 recombinant) Factor viii, (antihemophilic factor, Novoeight J7182 recombinant) Factor xiii (antihemophilic factor, human) N/A J7180 Factor xiii a-subunit, (recombinant) N/A J7181 Ferric Derisomaltose Monoferric J1437 * Neupogen J1442 Yes Filgrastim- TBO * Granix J1447 Yes Filgrastim-aafi * Nivestym Q5110 Yes Givlarari J0223, C9056 Golimumab Simponi J1602 Hemophilia clotting factor not otherwise N/A J7199 classified Human fibrinogen concentrate, not N/A J7178 otherwise specified Hyaluronate polymers J3470 Hyaluronate polymers hyaluronidase, ovine J3471 Hyaluronate polymers hyaluronidase, ovine J3472 Hyaluronate polymers hyaluronidase, recombinant J3473 Hyaluronate polymers * Hyaluronan or derivative, euflexxa J7323 Yes Hyaluronate polymers * Hyaluronan or derivative, gel-one J7326 Yes Hyaluronate polymers * Hyaluronan or derivative, hyalgan, J7321 Yes supartz or visco-3 Hyaluronate polymers * Hyaluronan or derivative, hymovis J7322 Yes Hyaluronate polymers * Hyaluronan or derivative, monovisc J7327 Yes Hyaluronate polymers * Hyaluronan or derivative, orthovisc J7324 Yes Hyaluronate polymers * Hyaluronan or derivitive, genvisc 850 J7320 Yes

Hyaluronate polymers * Hyaluronan or derivative, Trivisc J7329 Yes Hyaluronate polymers * Hyaluronan or derivative, Synojoynt J7331 Yes Hyaluronate polymers * Hyaluronan or derivative, Triluron J7332 Yes Hyaluronate polymers * Hyaluronan or derivative, Visco-3 J7333 Yes Ibandronate Sodium Boniva J1740 Idecaptagene Cicleucel Abecma Car-T Cell Therapy Code not yet available

Immune globulin Asceniv C9072 Immune globulin (IgIV), (IV) N/A 90283 Immune Globulin/IVIG Gamma globulin J1460 Immune Globulin/IVIG Gamma globulin J1560 Immune Globulin/IVIG HepaGam B J1571, J1573 Immune Globulin/IVIG Many Names J1459, J1556, J1557 J1561, J1566, J1599 J1568, J1569, J1572

Immune Globulin/IVIG Many Names J1555, J1559,J1562, J1575, 90284 Incobotulinumtoxin type A Botox J0588 inebilizumab-cdon Uplizna J1823 Infliximab * Remicade J1745 Yes Infliximab-axxq * Avsola Q5121 Yes Injection, factor ix (antihemophilic factor, N/A J7195 recombinant), not otherwise specified Interferon beta-1a Many names J1826 Interferon beta-1b Many names J1830 Lanreotide Somatuline J1930 Leucovorin Calcium Calcium Folinate, Khapzory J0640 levoleucovorin Fusilev J0641, J0642 Llisocabtagene maraleucel Breyanzi Code not yet provided. Oxlumo C9074 Luspatercept-aamt Reblozyl J0896 Mepolizumab Nucala J2182 Natalizumab Tysabri J2323 N/A J2326 Ocrelizumab Ocrevus J2350 Octreotide Acetate Octreotide Acetate J2353, J2325 Omalizumab Xolair J2357 OnabotulinumtoxintypeA Botox J0585 -Xioi N/A J3399 Oprelvekin Neumega J2355 Pamidronate Aredia J2430 Patisiran Onpattro J0222 Neulasta J2505 Pegfilgrastim-apgf Nyvepria C9401, Q5122 Yes Pegfilgrastim-bmez * Ziextenzo Q5120 Yes Pegfilgrastim-jmdb * Fulphila Q5108 Yes Pegloticase Kyrystexxa J2507 Plerixafor Mozobil J2562 Rasburicase Elitek J2783 Ravulizumab-cwvz Ultomiris J1303 Rilonacept Arcalyst J2793 RimabotulinumtoxinB Botox J0587 Romiplostim Nplate J2796 Leukine J2820 Siltuximab Sylvant J2860 Steroids N/A N/A Taliglucerase Alfa Elelyso J3060 -trbw Tepezza J3241 Replacement Therapy Testopel J3490 Therapeutic Radiopharmaceuticals Therapeutic Radiolygy A9513, A9590, A9606, A9699 Tocilizumab Actemra J3262 Treprostinil Remodulin J3285 Treprostinil Tyvaso J7686 Triptorelin Pamoate Trelstar J3315 Unclassified Biologics Unclassified Biologics J3590 Unclassified Drugs Unclassified Drugs J3490, C9399 Ustekinumab Stelara J3357, J3358 Vedolizumab Entyvio J3380 Viltepso J1427 Viltepso C9071 Visco-3, Hyalgan, Supartx FX J7321 Von willebrand factor complex - vwf:rco Humate-p J7186, J7187 Von willebrand factor complex (human) - Wilate J7183 vwf:rco Zoledronic Acid Reclast, Zometa, J3489 All chemotherapy and biologic therapy Prior Authorization Is Required – injectable drugs with codes J9000-J9999 Effective 10/1/2019 All chemotherapy and biologic therapy Prior Authorization Is Required – injectable drugs that have a Q code Effective 10/1/2019 Antibiotics VOID - No Prior Authorization Required Antiemetics VOID - No Prior Authorization Required Antihistamines VOID - No Prior Authorization Required Steroids VOID - No Prior Authorization Required *STEP THERAPY- Effective for dates of service beginning 1/1/2021- Step Therapy prior authorization is requried for the (*) Part B and other Part B covered items that are not preferred products. Preferred medications/items (bolded below) DO NOT required Prior authorization. Step Therapy Category Drug / Medical Device Name HCPC Code Preferred Polymers (FDA approved as *Gelsyn-3 J7328 Yes medical devices) Hyaluronic Acid Polymers (FDA approved as *Durolane J7318 Yes Hyaluronic Acid Polymers (FDA approved as *Synvisc or Synvisc-One J7325 Yes Hyaluronic Acid Polymers (FDA approved as GenVisc 850 J7320 No Hyaluronic Acid Polymers (FDA approved as Hyalgan, Supartz, Supartz FX J7321 No Hyaluronic Acid Polymers (FDA approved as Hymovis J7322 No Hyaluronic Acid Polymers (FDA approved as Euflexxa J7323 No Hyaluronic Acid Polymers (FDA approved as Orthovisc J7324 No Hyaluronic Acid Polymers (FDA approved as Gel-One J7326 No Hyaluronic Acid Polymers (FDA approved as Monovisc J7327 No Hyaluronic Acid Polymers (FDA approved as Trivisc J7329 No Hyaluronic Acid Polymers (FDA approved as Synojoynt J7331 No Hyaluronic Acid Polymers (FDA approved as Triluron J7332 No Hyaluronic Acid Polymers (FDA approved as Visco-3 J7333 No Immunomodulators *Inflectra (Infliximab-dyyb) Q5103 Yes Immunomodulators *Renflexis (infliximab-abda) Q5104 Yes Immunomodulators Remicade (infliximab) J1745 No Immunomodulators Avsola (infliximab-axxq) Q5121 No Erythropoiesis- Stimulating Agents (Note: Epogen [Epoeting Alfa] and Mircera *Retacrit (epoetin alfa-epbx) Q5106 Yes [MethoxyPEG-Epoetin Beta] are not subject to step therapy requirements) Erythropoiesis- Stimulating Agents (Note: EpoAranesp (darbepoetin alfa) J0881 No Erythropoiesis- Stimulating Agents (Note: EpoProcrit (epoetin alfa) J0885 No Colony Stimulating Factors (Short-Acting) Xarxio (filgrastim-sndz) Q5101 Yes Colony Stimulating Factors (Short-Acting) Neupogen (filgrastim) J1442 No Colony Stimulating Factors (Short-Acting) Granix (tbo-filgrastim) J1447 No Colony Stimulating Factors (Short-Acting) Nivestym (filgrastim-aafi) Q5110 No Colony Stimulating Factors (Long-Acting) Neulasta (pegfilgrastim-jmdb) J2505 Yes Colony Stimulating Factors (Long-Acting) Udenyca (pegfilgratim-cbqv) Q5111 Yes Colony Stimulating Factors (Long-Acting) Fulphila (pegfilgratim-jmdb) Q5108 No Colony Stimulating Factors (Long-Acting) Ziextenzo (pegfilgrastim-bmez) Q5120 No Colony Stimulating Factors (Long-Acting) Nyvepria (pegfilgrastim-apgf) C9401 No Nyvepria (pegfilgrastim-apgf) Q5122 No Nebulizer Solutions (dispensed at a *Perforomist N/A Yes pharmacy ) Nebulizer Solutions (dispensed at a Brovana N/A No Yes (* for ARMD Only- 3 dose Vascular Endothelial (VEGF) *Compound Avastin (bevacizumab) J9035 attempt required to advance in step Inhibitors therapy) Yes (* for ARMD Only- 3 dose Vascular Endothelial Growth Factor (VEGF) *Compound Avastin (bevacizumab) C9257 attempt required to advance in step Inhibitors therapy) Vascular Endothelial Growth Factor (VEGF) Eylea J0178 No Vascular Endothelial Growth Factor (VEGF) Beovu J0179 No Vascular Endothelial Growth Factor (VEGF) Macugen J2503 No Vascular Endothelial Growth Factor (VEGF) Lucentis J2778 No

· This is the new prior authorization list for all Part B medications requiring prior authorization. This list may be updated frequently, so please watch for changes. · With EACH request, please provide any pertinent clinical information/chart notes for review by submitting them with your medication request via the MCS Prior Authorization Portal. · If a drug is not on this list, it does not require prior authorization and will be voided upon request (with the exception of unclassified drugs that do not have an assigned HCPCS code and require authorization). For any questions or concerns, please call the PHP Prior Authorization Department at 720-612-6700, option 1.