CareSource Just4Me™ Authorization Requirements for Medications Under the Medical Benefit The provided list is not all-inclusive. Any and all medications may be subject to review. This list will be updated quarterly. Revision/Review Date: 1/1/2016 Effective Date: 02/1/2016 Procedure Code Description Brand Authorization Requirements Interferon beta-1a, 30 mcg Avonex, Rebif Not Covered Under Medical Benefit, Pharmacy Only Authorization required for all J1826 providers Rho D immune globulin, human, minidose, 50 mcg (250 i.u.) Hyperho S/D, Micrhogam,Rhogam No authorization required for home, outpatient and MD office J2788 Rho D immune globulin, human, full dose, 300 mcg (1500 i.u.) Hyperho S/D, Gamulin, Rhophylac, No authorization required for home, outpatient and MD office J2790 Rhogam, Bayrho-D Rho D immune globulin, intravenous, human, solvent detergent, 100 Winrho SDF No authorization required for home, outpatient and MD office J2792 IU J9301 Obinutuzumab, 10 mg Injection Gazyva Authorization required for all providers J7508 Tacrolimus Oral Per 5 Mg Astagraf XL Not Covered Under Medical Benefit, Pharmacy Only J1071 Testosterone cypionate, 1 mg Injection Depo-Testosterone Authorization required for all providers J3121 Testosterone enanthate, 1 mg Injection Delatestryl Authorization required for all providers J3145 Testosterone undecanoate, 1 mg Injection Aveed Authorization required for all providers J1930 Lanreotide, 1 mg Somatuline Authorization required for all providers J2353 Octreotide, depot form for intramuscular 1 mg Sandostatin Authorization required for all providers Octreotide, nondepot form for subcutaneous or intravenous 25 mcg Sandostatin Authorization required for all providers J2354 J0171 Adrenalin, epinephrine, 0.1 mg Injection Adrenalin No authorization required for home, outpatient and MD office J1265 Dopamine HCl, 40 mg Intropin No authorization required for home, outpatient and MD office J2315 Naltrexone, depot form, 1 mg Vivitrol Authorization required for all providers J9340 Thiotepa, 15 mg Thioplex No authorization required for home, outpatient and MD office J0636 Calcitriol, 0.1 mcg Injection Calcitrol No authorization required for home, outpatient and MD office J3350 Urea, up to 40 g Injection Urea No authorization required for home, outpatient and MD office Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g Metvixia No authorization required for home, outpatient and MD office J7309 Alpha 1-proteinase inhibitor (human), not otherwise specified, 10 Zemaira, Prolastin, or Aralast Authorization required for all providers J0256 mg Injection Alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg Injection Glassia Authorization required for all providers J0257 J0881 Darbepoetin alfa, 1 mcg (non-ESRD use) Aranesp Authorization required for all providers J0882 Darbepoetin alfa, 1 mcg (for ESRD on dialysis) Aranesp Authorization required for all providers J0885 Epoetin alfa, (for non-ESRD use), 1000 units Epogen, Procrit Authorization required for all providers J0886 Epoetin alfa, 1000 units (for ESRD on dialysis) Epogen, Procrit Authorization required for all providers J0670 Mepivacaine HCl, per 10 ml Polocaine No authorization required for home, outpatient and MD office J2001 Lidocaine HCl for intravenous infusion, 10 mg Xylocaine No authorization required for home, outpatient and MD office J2250 Midazolam HCl, per 1 mg Versed No authorization required for home, outpatient and MD office J2704 Propofol, 10 mg Injection Diprivan No authorization required for home, outpatient and MD office J2793 Rilonacept, 1 mg Arcalyst Authorization required for all providers J2795 Ropivacaine HCl, 1 mg Naropin No authorization required for home, outpatient and MD office J2400 Chloroprocaine HCl, per 30 ml Nesacaine No authorization required for home, outpatient and MD office J1742 Ibutilide fumarate, 1 mg Corvert No authorization required for home, outpatient and MD office J2690 Procainamide HCl, up to 1 g Pronestyl No authorization required for home, outpatient and MD office J0745 Codeine phosphate, per 30 mg Codeine Phosphate No authorization required for home, outpatient and MD office J1600 Gold sodium thiomalate, up to 50 mg Mycochrysine, Aurolate No authorization required for home, outpatient and MD office J2910 Aurothioglucose, up to 50 mg Injection Solganal No authorization required for home, outpatient and MD office J0200 Alatrofloxacin mesylate, 100 mg Injection Trovan No authorization required for home, outpatient and MD office J0278 Amikacin sulfate, 100 mg Injection Amikin No authorization required for home, outpatient and MD office J0720 Chloramphenicol sodium succinate, up to 1 g Chloromycetin No authorization required for home, outpatient and MD office J0743 Cilastatin sodium; imipenem, per 250 mg Primaxin No authorization required for home, outpatient and MD office J0744 Ciprofloxacin for intravenous infusion, 200 mg Cipro No authorization required for home, outpatient and MD office J0770 Colistimethate sodium, up to 150 mg Coly-mycin M No authorization required for home, outpatient and MD office J0878 Daptomycin, 1 mg Cubicin No authorization required for home, outpatient and MD office J1267 Doripenem, 10 mg Doribax No authorization required for home, outpatient and MD office J1335 Ertapenem sodium, 500 mg Invanz No authorization required for home, outpatient and MD office J1840 Kanamycin sulfate, up to 500 mg Kantrex No authorization required for home, outpatient and MD office J1850 Kanamycin sulfate, up to 75 mg Kantrex No authorization required for home, outpatient and MD office J2010 Lincomycin HCl, up to 300 mg Lincocin No authorization required for home, outpatient and MD office J2020 Linezolid, 200 mg Zyvox No authorization required for home, outpatient and MD office J2185 Meropenem, 100 mg Merrem No authorization required for home, outpatient and MD office J2280 Moxifloxacin, 100 mg Avelox No authorization required for home, outpatient and MD office J2770 Quinupristin/dalfopristin, 500 mg (150/350) Synercid No authorization required for home, outpatient and MD office J3095 Injection, telavancin, 10 mg Vibativ No authorization required for home, outpatient and MD office J3243 Tigecycline, 1 mg Tygacil No authorization required for home, outpatient and MD office J0190 Biperiden lactate, per 5 mg Injection Akineton No authorization required for home, outpatient and MD office J0461 Atropine sulfate, 0.01 mg Injection Atropen No authorization required for home, outpatient and MD office J0515 Benztropine mesylate, per 1 mg Injection Cogentin No authorization required for home, outpatient and MD office J3250 Trimethobenzamide HCl, up to 200 mg Tigan No authorization required for home, outpatient and MD office Atropine, inhalation solution, compounded product, administered Atropine No authorization required for home, outpatient and MD office J7635 through DME, concentrated form, per mg Atropine, inhalation solution, compounded product, administered Atropine No authorization required for home, outpatient and MD office J7636 through DME, unit dose form, per mg J1245 Dipyridamole, per 10 mg Persantine No authorization required for home, outpatient and MD office J1642 Heparin sodium, (heparin lock flush), per 10 units Heparin No authorization required for home, outpatient and MD office J1644 Heparin sodium, per 1000 units Heparin No authorization required for home, outpatient and MD office J1645 Dalteparin sodium, per 2500 IU Fragmin No authorization required for home, outpatient and MD office J1650 Enoxaparin sodium, 10 mg Lovenox No authorization required for home, outpatient and MD office J1652 Fondaparinux sodium, 0.5 mg Arixtra No authorization required for home, outpatient and MD office J1655 Tinzaparin sodium, 1000 IU Innohep No authorization required for home, outpatient and MD office J1945 Lepirudin, 50 mg Refludan No authorization required for home, outpatient and MD office J1165 Phenytoin sodium, per 50 mg Phenytoin Sodium No authorization required for home, outpatient and MD office J1953 Levetiracetam, 10 mg Kepra No authorization required for home, outpatient and MD office J0470 Dimercaprol, per 100 mg Bal in Oil No authorization required for home, outpatient and MD office J0600 Edetate calcium disodium, up to 1,000 mg Calcium Disodium Versenate No authorization required for home, outpatient and MD office J0716 Centruroides immune f(ab)2, up to 120 mg Anascorp No authorization required for home, outpatient and MD office J0840 Crotalidae polyvalent immune fab (ovine), up to 1 g Crofab No authorization required for home, outpatient and MD office J1451 Fomepizole, 15 mg Injection Antizol No authorization required for home, outpatient and MD office J2212 Methylnaltrexone, 0.1 mg Relistor Authorization required for all providers J2310 Naloxone HCl, per 1 mg Narcan No authorization required for home, outpatient and MD office J2720 Protamine sulfate, per 10 mg Protamine Sulfate No authorization required for home, outpatient and MD office J2730 Pralidoxime chloride, up to 1 g Protopam No authorization required for home, outpatient and MD office J3520 Edetate disodium, per 150 mg Endrate No authorization required for home, outpatient and MD office Unclassified biologics Raptiva, Vespid, Yellow Hornet Authorization required for all providers, NDC Required Treatment, Yellow Jacket Treatment, Honey Bee Treatment, J3590 Hymenoptera Venom, Venomil, Albay Venomil, Anascorp, Tissuemend J0780 Prochlorperazine, up to 10 mg Compazine No authorization required for home, outpatient and MD office