1199SEIU Benefit Funds

Transcription

1 1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective January 1, 2019 As of April 1, 2015, providers must use the web-based ExpressPAth platform to obtain prior authorization of drug treatments. Register at If you have questions, please call (877) The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Authorization Program. The symbol [evicore] next to a drug name indicates that this medication is subject to the evicore Comprehensive Oncology Management Program. Please contact (888) for additional assistance. ACTEMRA TOCILIZUMAB INFLAMMATORY / ADAGEN PEGADEMASE BOVINE ENZYME DEFICIENCIES J2504 ADCIRCA ADCIRCA (TADALAFIL) PULMONARY HYPERTENSION PA J8499 ADEMPAS RIOCIGUAT CIRCULATION DISORDERS PA J8499 ADIPEX-P PHENTERMINE WEIGHT LOSS PA J8499 ADVATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7192 ADYNOVATE AFSTYLA FACTOR VIII (ANTIHEMOPHL FCTR) RECOMB PEGYLATED ANTIHEMOPHL FCTR (RECOMB) SINGLE CHAIN J3262 HEMOPHILIA C9137, J7199, J7207 HEMOPHILIA J7210 ALDURAZYME LARONIDASE ENZYME DEFICIENCIES CPA NO J1931 AIMOVIG ERENUMAB MIGRAINE PA C9399, J3590 AJOVY FREMANEZUMAB MIGRAINE PA C9399, J3590 ALPHANATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7186 ALPHANINE SD FACTOR IX COMPLEX (HUMAN) HEMOPHILIA J7193 ALPROLIX FACTOR IX Fc FUSION PROTEIN RECOMB HEMOPHILIA J7201 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

2 AMPYRA DALFAMPRIDINE MULTIPLE SCLEROSIS PA J8499 APOKYN APOMORPHINE HCL MISCELLANEOUS CNS DISORDERS ARALAST NP ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY PA J0256 ARCALYST RILONACEPT CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES J0364 PA J2793 ARISTADA ARIPIPRAZOLE LAUROXIL INJ MENTAL J1942 ATGAM LYMPHOCYTE IMMUNE GLOBULIN TRANSPLANT J7504 AUBAGIO TERIFLUNOMIDE MULTIPLE SCLEROSIS PA J8499 AUSTEDO DEUTETRABENAZINE MISCELLANEOUS CNS DISORDERS AVASTIN (compounded for ophthalmic administration see Bevacizumab) BEVACIZUMAB OPHTHALMIC / PA J8499 AVEED TESTOSTERONE UNDECANOATE ENDOCRINE DISORDERS PA J3145 C9257, J7999 AVONEX INTERFERON BETA-1A MULTIPLE SCLEROSIS PA J1826, Q3027 BEBULIN FACTOR IX COMPLEX (HUMAN) HEMOPHILIA J7194 BELVIQ LORCASERIN WEIGHT LOSS PA J8499 BENEFIX FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7195 BENLYSTA IV BELIMUMAB INFLAMMATORY PA J0490 BENLYSTA SC BELIMUMAB INFLAMMATORY PA C9399, J3590 BENZPHETAMINE BENZPHETAMINE WEIGHT LOSS PA J3490 BERINERT C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA PA J0597 BETASERON INTERFERON BETA-1B MULTIPLE SCLEROSIS PA J1830 BEVACIZUMAB (Brand Avastin - compounded for ophthalmic administration) BEVACIZUMAB OPHTHALMIC / CANCER C9257, J7999 BIVIGAM IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1556 BONIVA (IV) IBANDRONATE OSTEOPOROSIS PA J1740 BOTOX BOTULINUM TOXIN A NEUROMUSCULAR /COSMETIC PA J0585 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

3 BRINEURA CERLIPONASE ALFA MISCELLANEOUS SPECIALTY PA J0567 eff. 1/1/2019 CARIMUNE NF IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1566 CELLCEPT MYCOPHENOLATE MOFETIL TRANSPLANT J7517, J7599 CEPROTIN PROTEIN C CONCENTRATE, HUMAN MISCELLANEOUS SPECIALTY CERDELGA ELIGLUSTAT ENZYME DEFICIENCIES CPA J8499 CEREDASE ALGLUCERASE ENZYME DEFICIENCIES CPA NO J0205 CEREZYME IMIGLUCERASE ENZYME DEFICIENCIES CPA NO J1786 CHEMET SUCCIMER CHELATING AGENTS PA J8499 CHENODAL CHENODIOL MISCELLANEOUS SPECIALTY J2724 PA NO HCPC CIMZIA CERTOLIZUMAB PEGOL INFLAMMATORY PA J0717 CINQAIR RESLIZUMAB RESPIRATORY PA C9481, J2786 CINRYZE C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA PA J0598 COAGADEX FACTOR X HUMAN HEMOPHILIA J7175 CONTRAVE NALTREXONE/BUPROPRION WEIGHT LOSS PA J3490 COPAXONE GLATIRAMER ACETATE MULTIPLE SCLEROSIS PA J1595 COPEGUS RIBAVIRIN HEPATITIS C PA J8499 CORIFACT FACTOR XIII HEMOPHILIA J7180 COSENTYX SECUKINUMAB INFLAMMATORY PA C9399, J3590 CRYSVITA BUROSUMAB-TWZA METABOLIC DISORDER PA C9399, J0584 eff. 1/1/2019, J3590 CUBICIN DAPTOMYCIN INFECTIOUS DISEASE J0878 CUVITRU IMMUNE GLOBULIN - SQ IMMUNE DEFICIENCY PA J1555 CYTOGAM CYTOMEGALOVIRUS IMMUNE GLOB IMMUNE DEFICIENCY CPA 90291, J0850 DAKLINZA DACLATASVIR HEPATITIS C PA J8499 DALFAMPRIDINE DALFAMPRIDINE MULTIPLE SCLEROSIS PA J8499 DDAVP DESMOPRESSIN ACETATE ENDOCRINE DISORDERS J2597 DEFEROXAMINE MESYLATE DEPO- TESTOSTERONE DEFEROXAMINE MESYLATE IRON TOXICITY J0895 TESTOSTERONE CYPIONATE ENDOCRINE DISORDERS PA J1071 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

4 DESFERAL DEFEROXAMINE MESYLATE IRON TOXICITY J0895 DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE ENDOCRINE DISORDERS J2597 DIETHYLPROPION DIETHYLPROPION WEIGHT LOSS PA J3490 DOPTELET AVATROMBOPAG THROMBOCYTOPENIA PA C9399, J8499 DUPIXENT DUPILUMAB INFLAMMATORY PA C9399, J3590 DUROLANE SODIUM HYALURONATE, HYALURONIC ACID OSTEOARTHRITIS PA C9465, C9399 prior to 4/1/2018, J7318 eff. 1/1/2019, J3490 DYLOJECT DICLOFENAC SODIUM INJ PAIN MANAGEMENT J1130 DYSPORT ABOBOTULINUMTOXINA NEUROMUSCULAR /COSMETIC PA J0586 ELAPRASE IDURSULFASE ENZYME DEFICIENCIES CPA NO J1743 EGRIFTA TESAMORELIN ACETATE ENDOCRINE DISORDERS PA C9399, J3490 ELELYSO TALIGLUCERASE ALFA ENZYME DEFICIENCIES CPA NO J3060 ELIGARD LEUPROLIDE MISCELLANEOUS /CANCER ELOCTATE FACTOR IX Fc FUSION PROTEIN RECOMB PA J9217 HEMOPHILIA J7205 EMFLAZA DEFLAZACORT MUSCULAR DYSTROPHY PA J8499 EMGALITY GALCANEZUMAB MIGRAINE PA C9399, J3590 ENBREL ETANERCEPT INFLAMMATORY PA J1438 ENDARI L-GLUTAMINE MISCELLANEOUS SPECIALTY PA J8499 ENTYVIO VEDOLIZUMAB INFLAMMATORY PA J3380 EPCLUSA SOFOSBUVIR/VELPATASVIR HEPATITIS C PA J8499 EPIDIOLEX CANNABIDIOL MISCELLANEOUS SPECIALTY EPOPROSTENOL SODIUM PA J8499 EPOPROSTENOL NA PULMONARY HYPERTENSION PA J1325 EPOGEN EPOETIN ALFA BLOOD CELL DEFICIENCY/ ESBRIET PIRFENIDONE IDIOPATHIC PULMONARY FIBROSIS PA J8499 J0885, Q4081 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

5 EUFLEXXA SODIUM HYALURONATE OSTEOARTHRITIS PA J7323 EXJADE DEFERASIROX IRON TOXICITY PA J8499 EXTAVIA INTERFERON BETA-1B MULTIPLE SCLEROSIS PA J1830 EYLEA AFLIBERCEPT OPHTHALMIC PA J0178 FABRAZYME AGALSIDASE ENZYME DEFICIENCIES CPA NO J0180 FASENRA BENRALIZUMAB RESPIRATORY PA C9466, C9399 for billing prior to 4/1/2018, J0517 eff. 1/1/2019, J3590 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. HEMOPHILIA J7198 FERRIPROX DEFERIPRONE IRON TOXICITY PA J8499 FIRAZYR ICATIBANT ACETATE HEREDITARY ANGIOEDEMA PA J1744 FLEBOGAMMA DIF IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1572 FLOLAN EPOPROSTENOL NA PULMONARY HYPERTENSION PA J1325 FONDAPARINUX SODIUM FONDAPARINUX SODIUM ANTICOAGULANT J1652 FORTEO TERIPARATIDE OSTEOPOROSIS PA J3110 FUZEON ENFUVIRTIDE HIV J1324 GALAFOLD MIGALASTAT ENZYME DEFICIENCIES PA C9399, J8499 GAMASTAN S-D IMMUNE GLOBULIN - IM IMMUNE DEFICIENCY 90281, J1460, J1560 GAMMAGARD LIQUID IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, 90284, J1569 GAMMAGARD S-D IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1566 GAMMAKED IMMUNE GLOBULIN - IV/SQ IMMUNE DEFICIENCY PA 90283, 90284, J1561 GAMMAPLEX IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1557 GAMUNEX-C IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, 90284, J1561 GEL-ONE HYALURONATE SODIUM OSTEOARTHRITIS PA J7326 GELSYN-3 HYALURONATE SODIUM OSTEOARTHRITIS PA J7328 GENOTROPIN SOMATROPIN GROWTH DEFICIENCY PA J2941 GENVISC 850 HYALURONATE SODIUM OSTEOARTHRITIS PA Q9980, J7320 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

6 GILENYA FINGOLIMOD HYDROCHLORIDE MULTIPLE SCLEROSIS PA J8499 GLASSIA ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY PA J0257 GLATOPA GLATIRAMER ACETATE MULTIPLE SCLEROSIS PA J1595 GRASTEK TIMOTHY GRASS POLLEN ALLERGEN EXTRACT H.P. ACTHAR GEL CORTICOTROPIN MISCELLANEOUS CNS DISORDERS ASTHMA AND ALLERGY PA J3590, C9399 PA J0800 HAEGARDA C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA PA J0599 HARVONI LEDIPASVIR/SOFOSBUVIR HEPATITIS C PA J8499 HELIXATE FS FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7192 HEMLIBRA EMICIZUMAB HEMOPHILIA PA Q9995 eff. 7/1/2018, J7170 eff. 1/1/2019 HEMOFIL M FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7190 HEPAGAM B HEP.B IMMUNE GLOB/MALTOSE HEPATITIS B J1571, J1573 HETLIOZ TASIMELTEON MISC SPECIALTY PA J8499 HIZENTRA IMMUNE GLOBULIN- SQ IMMUNE DEFICIENCY PA 90284, J1559 HUMATE-P FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7187 HUMATROPE SOMATROPIN GROWTH DEFICIENCY PA J2941 HUMIRA ADALIMUMAB INFLAMMATORY PA J0135 HYALGAN SODIUM HYALURONATE OSTEOARTHRITIS PA J7321 HYDROXYPROGES- TERONE CAPROATE HYDROXYPROGESTERONE CAPROATE MISC SPECIALTY PA J1726 HYMOVIS HYALURONIC ACID OSTEOARTHRITIS PA C9471, J7322 HYPERHEP B S-D HEPATITIS B IMMUNE GLOBULIN HEPATITIS B HYPERRAB S-D RABIES IMMUNE GLOBULIN IMMUNE DEFICIENCY HYQVIA IMMUNE GLOBULIN - SQ IMMUNE DEFICIENCY PA J1575 IDELVION FACTOR IX ALBUMIN FUSION PROTEIN RECOMB ILARIS CANAKINUMAB CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES HEMOPHILIA C9139, J7202 PA J0638 ILUMYA TILDRAKIZUMAB INFLAMMATORY PA C9399, J3245 eff. 1/1/2019, J3590 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

7 ILUVIEN FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT OPHTHALMIC J7313 IMOGAM RABIES-HT RABIES IMMUNE GLOBULIN IMMUNE DEFICIENCY INCRELEX MECASERMIN GROWTH DEFICIENCY PA J2170 INFLECTRA INFLIXIMAB - DYYB INFLAMMATORY PA Q5103, Q5102 (code deleted 3/31/2018) INGREZZA VALBENAZINE MISCELLANEOUS CNS DISORDERS PA J8499 INVANZ ERTAPENEM INFECTIOUS DISEASE J1335 IXINITY COAGULATION FACTOR IX RECOMB HEMOPHILIA J7195 JIVI JM ANTIHEMOPHILIC FACTOR, AHF, FACTOR VIII ANTIHEMOPHILIC FACTOR, AHF, FACTOR VIII HEMOPHILIA PA NO C9399, J7199 HEMOPHILIA PA C9399, J7199 JADENU DEFERASIROX IRON TOXICITY PA J8499 JUXTAPID LOMITAPIDE HYPERCHOLESTEROLEMIA PA J8499 JYNARQUE TOLVAPTAN MISCELLANEOUS PA J8499 KALBITOR ECALLANTIDE HEREDITARY ANGIOEDEMA PA J1290 KALYDECO IVACAFTOR RESPIRATORY PA J8499 KANUMA SEBELIPASE ALFA ENZYME DEFICIENCIES CPA C9478, J2840 KCENTRA PROTHROMBIN COMPLEX HUMAN HEMOPHILIA C9132 KENALOG TRIAMCINOLONE ACETONIDE INFLAMMATORY J3301 KEVZARA SARILUMAB INFLAMMATORY PA C9399, J3590 KINERET ANAKINRA INFLAMMATORY / KOATE-DVI FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7190 KOGENATE FS FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7192 KORLYM MIFEPRISTONE ENDOCRINE DISORDERS PA J8499 KOVALTRY FACTOR VIII (ANTIHEMOPHL FCTR) RECOMB J3590 HEMOPHILIA NO J7211 KRYSTEXXA PEGLOTICASE INFLAMMATORY PA J2507 KUVAN SAPROPTERIN DIHYDROCHLORIDE ENDOCRINE DISORDERS PA J8499 KYLEENA LEVONORGESTREL CONTRACEPTIVE J7296 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

8 KYNAMRO MIPOMERSEN HYPERCHOLESTEROLEMIA PA C9399, J3490 LEMTRADA ALEMTUZUMAB MULTIPLE SCLEROSIS PA J0202 LETAIRIS AMBRISENTAN PULMONARY HYPERTENSION PA J8499 LILETTA LEVONORGESTREL CONTRACEPTIVE J7297 LOMAIRA PHENTERMINE WEIGHT LOSS PA J3490 LUCENTIS RANIBIZUMAB OPHTHALMIC PA J2778 LUMIZYME ALGLUCOSIDASE ALFA ENZYME DEFICIENCIES CPA NO J0221 LUPANETA LEUPROLIDE DEPOT/ NORETHINDRONE MISCELLANEOUS /CANCER LUPRON DEPOT LEUPROLIDE DEPOT MISCELLANEOUS /CANCER LUPRON DEPOT PED LEUPROLIDE DEPOT MISCELLANEOUS /CANCER PA C9399, J3490 PA J1950, J9217 PA J1950 LUXTURNA VORETIGENE NAPARVOVEC OPHTHALMIC PA C9032 eff. 7/1/2018, C9399, J3398 eff. 1/1/2019 MACUGEN PEGAPTANIB SODIUM OPHTHALMIC PA J2503 MAKENA HYDROXYPROGESTERONE CAPROATE MISC SPECIALTY PA J1726 MAVYRET GLECAPREVIR/PIBRENTASVIR HEPATITIS C PA J8499 MIRCERA EPOETIN BETA BLOOD CELL DEFICIENCY PA J0887, J0888 MIRENA LEVONORGESTREL CONTRACEPTIVE J7298 MODERIBA RIBAVIRIN HEPATITIS C J8499 MONOCLATE-P FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7190 MONONINE FACTOR IX COMPLEX (HUMAN) HEMOPHILIA J7193 MONOVISC SODIUM HYALURONATE OSTEOARTHRITIS PA J7327 MULPLETA LUSUTROMBOPAG THROMBOCYTOPENIA PA C9399, J8499 MYALEPT METRELEPTIN LIPODYSTROPHY PA J3590, C9399 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL TRANSPLANT J7517 MYFORTIC MYCOPHENOLATE SODIUM TRANSPLANT J7518 MYOBLOC BOTULINUM TOXIN TYPE B NEUROMUSCULAR /COSMETIC PA J0587 NABI-HB HEPATITIS B IMMUNE GLOBULIN HEPATITIS B Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

9 NAGLAZYME GALSULFASE ENZYME DEFICIENCIES CPA NO J1458 NATPARA PARATHYROID HORMONE ENDOCRINE DISORDERS PA C9399, J3590 NEUPOGEN FILGRASTIM, G-CSF BLOOD CELL DEFICIENCY/ NEXPLANON ETONOGESTREL CONTRACEPTIVE J7307 NORDITROPIN SOMATROPIN GROWTH DEFICIENCY PA J2941 NIVESTYM FILGRASTIM-aafi BLOOD CELL DEFICIENCY/ NOVOEIGHT FACTOR VIII (ANTIHEMOPHL FCTR) RECOMB J1442 Q5110 HEMOPHILIA J7182 NOVOSEVEN RT FACTOR VIIA, RECOMB (BHK CELLS) HEMOPHILIA J7189 NPLATE ROMIPLOSTIM THROMBOCYTOPENIA PA J2796 NUCALA MEPOLIZUMAB RESPIRATORY PA C9473, J2182 NULOJIX BELATACEPT TRANSPLANT PA J0485 NUPLAZID PIMAVANSERIN MENTAL/NEURO DISORDERS PA J8499 NUTROPIN SOMATROPIN GROWTH DEFICIENCY PA J2941 NUVARING NUWIQ OBIZUR ETONOGESTREL/ETHYINYL ESTRADIOL FACTOR VIII (ANTIHEMOPHL FCTR) RECOMB ANTIHEMOPHL FCTR (RECOMB) PORCINE SEQUENCE CONTRACEPTIVE J7303 HEMOPHILIA C9138, J7209 HEMOPHILIA J7194 OCREVUS OCRELIZUMAB MULTIPLE SCLEROSIS PA J2350 OCTAGAM IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1568 OCTREOTIDE ACETATE OCTREOTIDE ENDOCRINE DISORDERS J2354 OFEV NINTEDANIB IDIOPATHIC PULMONARY FIBROSIS PA J8499 OLUMIANT BARICITINIB INFLAMMATORY PA C9399, J8499 OLYSIO SIMEPREVIR HEPATITIS C PA J8499 OMNITROPE SOMATROPIN GROWTH DEFICIENCY PA J2941 ONPATTRO PATISIRAN AMYLOIDOSIS PA C9036 eff. 1/1/2019, C9399, J3490 OPSUMIT MACITENTAN PULMONARY HYPERTENSION PA J8499 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

10 ORALAIR MIXED GRASS POLLENS ALLERGENS EXTRACT ASTHMA AND ALLERGY PA J3590, C9399 ORENCIA ABATACEPT/MALTOSE INFLAMMATORY PA J0129 ORENITRAM TREPROSTINIL PULMONARY HYPERTENSION PA J8499 ORKAMBI LUMACAFTOR/IVACAFTOR CYSTIC FIBROSIS PA J8499 ORTHOVISC HYALURONATE SODIUM OSTEOARTHRITIS PA J7324 OTEZLA APREMILAST INFLAMMATORY PA J8499 OTIPRIO CIPROFLOXACIN ANTI-INFECTIVE J7342 OZURDEX DEXAMETHASONE, INTRAVITREAL IMPLANT OPHTHALMIC J7312 PALYNZIQ PEGVALIASE METABOLIC DISORDER PA C9399, J3590 PANZYGA IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1599 PARAGARD COPPER INTRAUTERINE DEVICE CONTRACEPTIVE J7300 PEGASYS PEGINTERFERON ALFA-2A HEPATITIS/ PEGINTRON PEGINTERFERON ALFA-2A HEPATITIS/ PHENDIMETRAZINE PHENDIMETRAZINE WEIGHT LOSS PA J3490 S0145, J3590 S0148, J3590 PLEGRIDY PEGINTERFERON BETA-1A MULTIPLE SCLEROSIS PA J3590, C9399 PRALUENT ALIROCUMAB HYPERCHOLESTEROLEMIA PA C9399, J3590 PRIALT ZICONOTIDE ACETATE PAIN MANAGEMENT J2278 PRIVIGEN IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY PA 90283, J1459 PROBUPHINE IMPLANT BUPRENORPHINE HCL MISCELLANEOUS SPECIALTY PROCRIT EPOETIN ALFA BLOOD CELL DEFICIENCY/ PROFILNINE/ PROFILNINE SD J0570 FACTOR IX COMPLEX (HUMAN) HEMOPHILIA J7194 PROGESTERONE PROGESTERONE ENDOCRINE DISORDERS J2675 J0885, Q4081 PROGRAF TACROLIMUS TRANSPLANT J7507, J7525 PROLASTIN-C ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY PA J0256 PROLIA DENOSUMAB OSTEOPOROSIS/ PA J0897 PROMACTA ELTROMBOPAG OLAMINE THROMBOCYTOPENIA PA J8499 PULMOZYME DEOXYRIBONUCLEASE RESPIRATORY J7639 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

11 QSYMIA PHENTERMINE; TOPIRAMATE WEIGHT LOSS PA J8499 RADICAVA EDAVARONE AMYOTROPHIC LATERAL SCLEROSIS PA C9493, J1301 eff. 1/1/2019 RAPAMUNE SIROLIMUS TRANSPLANT J7520 REBETOL RIBAVIRIN HEPATITIS C PA J8499 REBIF INTERFERON BETA-1A/ALBUMIN MULTIPLE SCLEROSIS PA Q3028 REBINYN FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) HEMOPHILIA C9468, J7203, J7199 RECLAST ZOLEDRONIC ACID OSTEOPOROSIS/ PA J3489 RECOMBINATE FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) HEMOPHILIA J7192 REGIMEX BENZPHETAMINE WEIGHT LOSS PA J3490 REMICADE INFLIXIMAB INFLAMMATORY PA J1745 REMODULIN TREPROSTINIL SODIUM PULMONARY HYPERTENSION PA J3285 RENFLEXIS INFLIXIMAB - abda INFLAMMATORY PA Q5104 REPATHA EVOLOCUMAB HYPERCHOLESTEROLEMIA PA C9399, J3590 RETACRIT EPOETIN ALFA BLOOD CELL DEFICIENCY/ Q5105, Q5106 REVATIO SILDENAFIL CITRATE PULMONARY HYPERTENSION PA J3490, J8499 RIBAPAK RIBAVIRIN HEPATITIS C PA J8499 RIBASPHERE RIBAVIRIN HEPATITIS C PA J8499 RIBAVIRIN RIBAVIRIN HEPATITIS C PA J8499 RITUXAN RITUXIMAB INFLAMMATORY / RIXUBIS FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINANT) HEMOPHILIA J7200 RUCONEST C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA PA J0596 SAIZEN SOMATROPIN GROWTH DEFICIENCY PA J2941 SANDOSTATIN OCTREOTIDE ENDOCRINE DISORDERS J2354 SANDOSTATIN LAR OCTREOTIDE ENDOCRINE DISORDERS J2353 SAXENDA LIRAGLUTIDE WEIGHT LOSS PA J3490 SEROSTIM SOMATROPIN GROWTH DEFICIENCY PA J2941 J9310, J9312 eff. 1/1/2019 SIGNIFOR PASIREOTIDE DIASPARTATE ENDOCRINE DISORDERS PA C9399, J3490 SIGNIFOR LAR PASIREOTIDE DIASPARTATE INJ ENDOCRINE DISORDERS PA C9454, J2502 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

12 SILDENAFIL CITRATE SILDENAFIL CITRATE PULMONARY HYPERTENSION PA J3490, J8499 SILIQ BRODALUMAB INFLAMMATORY PA J3590 SIMPONI GOLIMUMAB INFLAMMATORY PA C9399, J3590 SIMPONI ARIA GOLIMUMAB INFLAMMATORY PA J1602 SIMULECT BASILIXIMAB TRANSPLANT J0480 SKYLA LEVONORGESTREL CONTRACEPTIVE J7301 SOLESTA DEXTRANOMER/HYALURONATE/ SOD MISCELLANEOUS SPECIALTY SOLIRIS ECULIZUMAB MISCELLANEOUS SPECIALTY L8605 PA J1300 SOMATULINE DEPOT LANREOTIDE ACETATE ENDOCRINE DISORDERS J1930 SOVALDI SOFOSBUVIR HEPATITIS C PA J8499 SPINRAZA NUSINERSEN NEUROMUSCULAR PA J2326 STELARA SC USTEKINUMAB INFLAMMATORY PA J3357 STELARA IV USTEKINUMAB INFLAMMATORY PA J3358 STRENSIQ ASFOTASE ALFA ENZYME DEFICIENCIES PA C9399, J3590 SUPARTZ FX HYALURONATE SODIUM OSTEOARTHRITIS PA J7321 SYMDEKO TEZACAFTOR/IVACAFTOR CYSTIC FIBROSIS PA J8499 SYNAGIS PALIVIZUMAB RSV PREVENTION PA SYNVISC HYALURONATE SODIUM OSTEOARTHRITIS PA J7325 SYNVISC-ONE HYALURONATE SODIUM OSTEOARTHRITIS PA J7325 TACROLIMUS TACROLIMUS TRANSPLANT J7507 TADALAFIL TADALAFIL PULMONARY HYPERTENSION PA J8499 TAKHZYRO LANADELUMAB HEREDITARY ANGIOEDEMA PA C9399, J3590 TALTZ IXEKIZUMAB RESPIRATORY PA J3490 TAVALISSE FOSTAMATINIB THROMBOCYTOPENIA PA J8499 TECFIDERA DIMETHYL FUMARATE MULTIPLE SCLEROSIS PA J8499 TECHNIVIE OMBITASVIR, PARITAPREVIR, AND RITONAVIR HEPATITIS C PA J8499 TEFLARO CEFTAROLINE INFECTIOUS DISEASE J0712 TEGSEDI INOTERSEN AMYLOIDOSIS PA C9399, J3490 TESTOPEL TESTOSTERONE PELLET ENDOCRINE DISORDERS PA S0189 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

13 TESTOSTERONE ENANTHATE TESTOSTERONE ENANTHATE ENDOCRINE DISORDERS PA J3121 THYMOGLOBULIN LYMPHOCYTE IMMUNE GLOBULIN TRANSPLANT J7511 TOBI TOBRAMYCIN/SODIUM CHLORIDE RESPIRATORY J3535, J7682 TRACLEER BOSENTAN PULMONARY HYPERTENSION PA J8499 TREMFYA GUSELKUMAB INFLAMMATORY PA J1628 eff. 1/1/2019 TRETTEN FACTOR XIII A-SUBUNIT, (RECOMBINANT) TRIPTODUR TRIPTORELIN MISCELLANEOUS /CANCER HEMOPHILIA J7181 PA C9016, J3316 eff. 1/1/2019, J3490 TRIVISC HYALURONATE SODIUM OSTEOARTHRITIS PA J7329 eff. 1/1/2019, J3490 TROGARZO IBALIZUMAB HIV PA C9399, J1746 eff. 1/1/2019, J3590 TYMLOS ABALOPARATIDE OSTEOPOROSIS PA C9399, J3490 TYSABRI NATALIZUMAB MULTIPLE SCLEROSIS PA J2323 TYVASO TREPROSTINIL (TYVASO) PULMONARY HYPERTENSION PA J7686 UPTRAVI SELEXIPAG PULMONARY HYPERTENSION PA J8499 VAPRISOL CONIVAPTAN MISCELLANEOUS SPECIALTY VELETRI EPOPROSTENOL NA PULMONARY HYPERTENSION PA J1325 VENTAVIS ILOPROST PULMONARY HYPERTENSION PA Q4074 VIEKIRA PAK VIEKIRA XR OMBITASVIR, PARITAPREVIR AND RITONAVIR; DASABUVIR OMBITASVIR, PARITAPREVIR AND RITONAVIR; DASABUVIR C9488 HEPATITIS C PA J8499 HEPATITIS C PA J8499 VIMIZIM ELOSULFASE ALFA ENZYME DEFICIENCIES CPA NO C9022, J1322 VISCO-3 HYALURONATE SODIUM OSTEOARTHRITIS PA J7321 VISUDYNE VERTEPORFIN OPHTHALMIC J3396 VIVITROL NALTREXONE MICROSPHERES MISCELLANEOUS CNS DISORDERS VONVENDI VON WILLEBRAND FACTOR (RECOMBINANT) J2315 HEMOPHILIA J7179 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against

14 VOSEVI SOFOSBUVIR; VELPATASVIR; VOXILAPREVIR HEPATITIS C PA J8499 VPRIV VELAGLUCERASE ALFA ENZYME DEFICIENCIES CPA NO J3385 WILATE VON WILLEBRAND FACTOR COMPLEX (HUMAN) HEMOPHILIA J7183 XELJANZ TOFACITINIB INFLAMMATORY PA J8499 XENAZINE TETRABENAZINE MISCELLANEOUS CNS DISORDERS PA J8499 XENICAL ORLISTAT WEIGHT LOSS PA J3490 XEOMIN INCOBOTULINUMTOXINA NEUROMUSCULAR /COSMETIC XGEVA DENOSUMAB XIAFLEX COLLAGENASE CLOSTRIDIUM HIST. MISCELLANEOUS SPECIALTY PA J0588 XOLAIR OMALIZUMAB RESPIRATORY PA J2357 XULANE XYNTHA/XYNTHA SOLOFUSE NORELGESTROMIN/ETHINYL ESTRADIOL J0897 J0775 CONTRACEPTIVE J7304 FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA J7185 ZARXIO FILGRASTIM-sndz BLOOD CELL DEFICIENCY/ ZAVESCA MIGLUSTAT ENZYME DEFICIENCIES CPA J8499 ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY PA J0256 ZEPATIER ELBASVIR/GRAZOPREVIR HEPATITIS C PA J8499 ZILRETTA TRIAMCINOLONE MICROSPHERES OSTEOARTHRITIS J3304 ZINPLAVA BEZLOTOXUMAB INFECTIOUS DISEASE J0565 ZOLEDRONIC ACID ZOLEDRONIC ACID OSTEOPOROSIS/ PA J3489 ZOMACTON SOMATROPIN GROWTH DEFICIENCY PA J2941 ZOMETA ZOLEDRONIC ACID OSTEOPOROSIS/ PA J3489 ZORBTIVE SOMATROPIN GROWTH DEFICIENCY PA J2941 Billing for any drug or biologic acquired with a 340B drug pricing program discount requires the use of JG or TB modifier effective 1/1/2018. s where there is a Prior Authorization requirement will have claims checked against Q5101