Drugs requiring transmission of a diagnosis code

You must include the ICD-10 diagnosis code on all claims for the drugs listed in this table. The purpose of this information is to minimize cost and ensure appropriate use and without restricting access to preferred products through prior authorization for diagnosis verification.

Medication Brand Name Medication Generic Name COPD ANORO ELLIPTA UMECLIDINIUM BRM/VILANTEROL TR ARCAPTA NEOHALER INDACATEROL MALEATE BEVESPI AEROSPHERE GLYCOPYRROLATE/FORMOTEROL FUM BROVANA ARFORMOTEROL TARTRATE COMBIVENT RESPIMAT IPRATROPIUM/ALBUTEROL SULFATE INCRUSE ELLIPTA UMECLIDINIUM BROMIDE PERFOROMIST FORMOTEROL FUMARATE SEEBRI NEOHALER GLYCOPYRROLATE SPIRIVA TIOTROPIUM BROMIDE SPIRIVA RESPIMAT TIOTROPIUM BROMIDE STIOLTO RESPIMAT TIOTROPIUM BR/OLODATEROL HCL STRIVERDI RESPIMAT OLODATEROL HCL TRELEGY ELLIPTA FLUTICASONE/UMECLIDIN/VILANTER TUDORZA PRESSAIR ACLIDINIUM BROMIDE UTIBRON NEOHALER INDACATEROL/GLYCOPYRROLATE Diabetes ADLYXIN LIXISENATIDE BYDUREON EXENATIDE MICROSPHERES BYDUREON BCISE EXENATIDE MICROSPHERES BYDUREON PEN EXENATIDE MICROSPHERES BYETTA EXENATIDE OZEMPIC SEMAGLUTIDE TANZEUM ALBIGLUTIDE TRULICITY DULAGLUTIDE VICTOZA 2-PAK LIRAGLUTIDE Immunomodulators ACTEMRA TOCILIZUMAB CIMZIA CERTOLIZUMAB PEGOL COSENTYX PEN SECUKINUMAB COSENTYX SYRINGE SECUKINUMAB ENBREL ETANERCEPT ENBREL MINI ETANERCEPT ENBREL SURECLICK ETANERCEPT Medication Brand Name Medication Generic Name HUMIRA ADALIMUMAB HUMIRA PEN ADALIMUMAB KEVZARA SARILUMAB KINERET ANAKINRA ORENCIA ABATACEPT/MALTOSE ORENCIA ABATACEPT ORENCIA CLICKJECT ABATACEPT OTEZLA APREMILAST SILIQ BRODALUMAB SIMPONI GOLIMUMAB SIMPONI ARIA GOLIMUMAB STELARA USTEKINUMAB TALTZ AUTOINJECTOR (3 PACK) IXEKIZUMAB TALTZ SYRINGE IXEKIZUMAB TREMFYA GUSELKUMAB XELJANZ TOFACITINIB CITRATE XELJANZ XR TOFACITINIB CITRATE Interferons PEGASYS PEGINTERFERON ALFA-2A PEGASYS PROCLICK PEGINTERFERON ALFA-2A PEGINTRON PEGINTERFERON ALFA-2B SYLATRON PEGINTERFERON ALFA-2B Meds that cost over $3000/prescription ARCALYST RILONACEPT BENLYSTA BELIMUMAB BUPHENYL SODIUM PHENYLBUTYRATE CARBAGLU CARGLUMIC ACID CERDELGA ELIGLUSTAT TARTRATE CHENODAL CHENODIOL CHOLBAM CHOLIC ACID CUPRIMINE PENICILLAMINE DARAPRIM PYRIMETHAMINE DUPIXENT DUPILUMAB ESBRIET PIRFENIDONE ILARIS CANAKINUMAB/PF KEVEYIS DICHLORPHENAMIDE KORLYM MIFEPRISTONE NATPARA PARATHYROID HORMONE OCALIVA OBETICHOLIC ACID ORFADIN NITISINONE ORKAMBI LUMACAFTOR/IVACAFTOR Medication Brand Name Medication Generic Name PHENOXYBENZAMINE HCL PHENOXYBENZAMINE HCL PROMACTA ELTROMBOPAG OLAMINE RAVICTI GLYCEROL PHENYLBUTYRATE SAMSCA TOLVAPTAN SOMAVERT PEGVISOMANT STRENSIQ ASFOTASE ALFA ZAVESCA MIGLUSTAT Oral Anticoagulants ELIQUIS APIXABAN XARELTO RIVAROXABAN PRADAXA DABIGATRAN ETEXILATE MESYLATE SAVAYSA EDOXABAN TOSYLATE Pulmonary Hypertension ADEMPAS RIOCIGUAT TRACLEER BOSENTAN EPOPROSTENOL SODIUM EPOPROSTENOL SODIUM (GLYCINE) ORENITRAM ER TREPROSTINIL DIOLAMINE VELETRI EPOPROSTENOL SODIUM (ARGININE) VENTAVIS ILOPROST TROMETHAMINE Testosterone ANDRODERM TESTOSTERONE ANDROGEL TESTOSTERONE FORTESTA TESTOSTERONE NATESTO TESTOSTERONE TESTIM TESTOSTERONE TESTOPEL TESTOSTERONE TESTOSTERONE TESTOSTERONE Other ACTIVASE ALTEPLASE ADDERALL DEXTROAMPHETAMINE/AMPHETAMINE ADDERALL XR DEXTROAMPHETAMINE/AMPHETAMINE ER APLENZIN BUPROPION HBR BUPROPION HCL BUPROPION HCL BUPROPION HCL SR BUPROPION HCL SR BUPROPION XL BUPROPION XL CATHFLO ACTIVASE ALTEPLASE FORFIVO XL BUPROPION HCL LYRICA CR PREGABALIN MARINOL DRONABINOL NALTREXONE HCL NALTREXONE HCL Medication Brand Name Medication Generic Name NUVIGIL ARMODAFINIL PROVIGIL MODAFINIL QUDEXY XR TOPIRAMATE TOPAMAX TOPIRAMATE TOPIRAMATE TOPIRAMATE TROKENDI XR TOPIRAMATE WELLBUTRIN SR BUPROPION HCL SR WELLBUTRIN XL BUPROPION XL