Authorizations for Medical

For phase 1 drugs on or after April 28, 2021 and for phase 2 drugs on or after June 16, 2021, you can request authorizations via the following: 1. Fax to 1-888-348-7332 or 2. Submit via the CoverMyMeds portal at https://www.covermymeds.com/main/

For assistance with authorizations or questions about denials: 1. Dial the same 800-672-7897 located on the back of the member ID care for the “Prior Review/Certification” department. 2. After hearing the welcome message, press #3 “Authorizations for a .” Then, select one of the following: Press #1: “Calls in response to a denial notification.” Press #2: “Calling in regards to a medication administered by the provider.” Press #3: “For all other Medication requests.” This will route the provider to pharmacy staff who can answer other questions regarding prescription authorizations or PBM rejection claim issues. Phase Number Effective Date* Drug** HCPCS Code** 1 4/28/2021 Actemra (tocilizumab) J3262 1 4/28/2021 Avsola (infliximab-axxq) Q5121 1 4/28/2021 Benlysta (belimumab) J0490 1 4/28/2021 Botox (onabotulinumtoxinA) J0585 1 4/28/2021 Cimzia (certolizumab pegol) J0717 1 4/28/2021 Cinqair (reslizumab) J2786 1 4/28/2021 Durolane () J7318 1 4/28/2021 Dysport (abobotulinumtoxinA) J0586 1 4/28/2021 Entyvio (vedolizumab) J3380 1 4/28/2021 Euflexxa (hyaluronic acid) J7323 1 4/28/2021 Fasenra (benralizumab) J0517 1 4/28/2021 Gel-One (hyaluronic acid) J7326 1 4/28/2021 Gelsyn-3 (hyaluronic acid) J7328 1 4/28/2021 Genvisc 850 (hyaluronic acid) J7320 1 4/28/2021 Hyalgan, Supartz (hyaluronic acid) J7321 1 4/28/2021 Hymovis (hyaluronic acid) J7322 1 4/28/2021 Ilumya (tildrakizumab-asmn) J3245 1 4/28/2021 Inflectra (infliximab-dyyb) Q5103 1 4/28/2021 Ixifi (infliximab-qbtx) Q5109 1 4/28/2021 Monovisc (hyaluronic acid) J7327 1 4/28/2021 Myobloc (botulinum toxin type B) J0587 1 4/28/2021 Nucala (mepolizumab) J2182 1 4/28/2021 Orencia (abatacept) J0129 1 4/28/2021 Orthovisc (hyaluronic acid) J7324 1 4/28/2021 Remicade (infliximab) J1745 1 4/28/2021 Renflexis (infliximab-abda) Q5104 1 4/28/2021 Sandostatin (octreotide) J2354 1 4/28/2021 Sandostatin LAR Depot (octreotide) J2353 1 4/28/2021 Signifor LAR (pasireotide) J2502 1 4/28/2021 Simponi Aria (golimumab) J1602 1 4/28/2021 Somatuline Depot (lanreotide) J1930 1 4/28/2021 Stelara (ustekinumab) IV J3358 1 4/28/2021 Stelara (ustekinumab) SQ J3357 1 4/28/2021 Synojoynt (hyaluronic acid) J7331 1 4/28/2021 Synvisc, Synvisc-One (hyaluronic acid) J7325 1 4/28/2021 Tremfya (guselkumab) J1628 1 4/28/2021 Triluron (hyaluronic acid) J7332 1 4/28/2021 Trivisc (hyaluronic acid) J7329 1 4/28/2021 Visco-3 (hyaluronic acid) J7333 1 4/28/2021 Xeomin (incobotulinumtoxinA) J0588 1 4/28/2021 Xolair (omalizumab) J2357

*Effective Dates are subject to change.

**Drug list and HCPCS codes may not be all-inclusive and may be subject to change closer to effective dates listed. Phase Number Effective Date* Drug** HCPCS Code** 2 6/16/2021 Adakveo (crizanlizumab-tmca) J0791 2 6/16/2021 Aldurazyme (laronisdase) J1931 2 6/16/2021 Aralast NP (alpha 1 proteinase inhibitor) J0256 2 6/16/2021 Asceniv (immune globulin) C9072, J3490, J3590 2 6/16/2021 Berinert (C1 esterase inhibitor (human)) J0597 2 6/16/2021 Bivigam (immune globulin) J1556 2 6/16/2021 Brineura (cerliponase alfa) J0567 2 6/16/2021 Probuphine (buprenorphine) implant J0570 2 6/16/2021 Cerezyme (imiglucerase) J1786 2 6/16/2021 Cinryze (C1 esterase inhibitor (human)) J0598 2 6/16/2021 Crysvita (burosumab-twza) J0584 2 6/16/2021 Cutaquig (immune globulin) - SCIg C9399, J3490, J3590 2 6/16/2021 Cuvitru (immune globulin) - SCIg J1555 2 6/16/2021 Durysta (bimatoprost) implant J7351 2 6/16/2021 Elaprase (idursulfase) J1743 2 6/16/2021 Eleylyso (taliglucerase alpha) J3060 2 6/16/2021 Evenity (romosozumab-aqqg) J3111 2 6/16/2021 Exondys 51 (