INJECTABLE MEDICINES. Resources, Links or Additional Information. J Code Brand Names Generic names Prior Authorization or Restrictions
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1 J FU fluorouracil None. J0401 ABILIFY MAINTENA aripiprazole i.v. J9264 ABRAXANE paclitaxel protein bound J3262 ACTEMRA IV tocilizumab Yes, through Navitus. Restricted to (in at least consultation with) psychiatry with Yes, through Navitus. Restricted to oncologists with prior authorization through Navitus Yes, through Navitus. Restricted to rheumatology specialists with prior authorization through Navitus ABILIFY MAINTENA (aripiprazole) ABRAXANE (paclitaxel protein bound) ACTEMRA IV (tocilizumab) J2997 ACTIVASE alteplase None. J7620 ALBUTEROL, VENTOLIN, PROVENTIL albuterol sulfate inhalation solution administered through DME None. J1931 ALDURAZYME laronidase Yes, through Navitus. ALDURAZYME (laronidase) J9305 ALIMTRA pemetrexed None. J2469 ALOXI palonosetron None. J0583 ANGIOMAX bivalirudin None. J7192, J7189, J7190, J7199, J7211, J7182, J7209, J7185, J7207, J7205, J7188, J7186, J7187, J7183, J7179, J7193, J7194, J7195, J7200, J7202, J7201, J7175, J7180, J7181, ANTIHEMOPHILIA FACTOR J0256 ARALAST, PROLASTIN alpha 1 antitrypsin J0882 ARANESP darbepoetin alfa, 1 mcg (for esrd on dialysis) Yes, through Prevea360 Health Plan Quality and Care Management. Restricted to hematology specialists with prior authorization Yes, through Navitus. Limited to Pulmonology with Yes, through Navitus. Restricted to (in at least consultation with) infectious disease, hematology, nephrology, or oncology with Antihemophilia Factors and Clotting Factors Alpha 1 Antitrypsin ARANESP (darbepoetin alpha) J0881 ARANESP darbepoetin alfa, 1 mcg (non-esrd use) Yes, through Navitus. Restricted to (in at least consultation with) infectious disease, hematology, nephrology, or oncology with ARANESP (darbepoetin alpha) J2430 AREDIA pamidronate disodium /30 mg None. Page 1 of 10
2 J7644 ATROVENT ipratropium bromide None. J9035 AVASTIN bevacizumab J9023 BAVENCIO avelumab Yes, through Navitus. Restricted to oncology and ophthamology specialists. Not covered. Exception to Coverage Request required and restricted to specialty provider for condition. Use standard Exception to Coverage PA form and send to Prevea360 Health Plan Utilization Management Dept. Fax (608) AVASTIN (bevacizumab) Exception to Coverage PA form J9031 BCG, TICE, THERACYS bcg live intravesical vac None. J9040 BLENOXANE bleomycin sulfate None. J0585 BOTOX onabotulinumtoxin Yes, through Prevea360 Health Plan Quality and Care Management Botulinum Toxin J9206 CAMPTOSAR irinotecan, 20mg None. J1786 CEREZYME imiglucerase None. J0717 CIMZIA IV certolizumab J2786 CINQAIR reslizumab Yes, through Navitus. Limited to Rheumatology for RA, psoriatic arthritis, or ankylosing spondylitis, and GI for Crohn's disease with SQ version may also be covered via member's pharmacy benefit. Yes, through Navitus. Limited to Pulmonology, Allergy, and Immunology specialists with CIMZIA (certolizumab pegol) CINQAIR (reslizumab) J9060 CISPLATIN cisplatin None. J0834 CORTROSYN cosyntropin (cortrosyn) None. J9120 COSMEGEN dactinomycin None. J0878 CUBICIN daptomycin injection None. J9100 CYTARABINE cytarabine None. J9070 CYTROXAN cyclophosphamide None. Page 2 of 10
3 J0894 DACOGEN decitabine injection None. J1055 DEPO-PROVERA medroxyprogesterone acetate, for contraceptive use 150mg None. J1110 DHE dihydroergotamine None. J9001 DOXIL doxorubicin hcl liposome None. J9130 DTIC dacarbazine None. J0586 DYSPORT abobotulinumtoxina Yes, through Prevea360 Health Plan Quality and Care Management Botulinum Toxin J9263 ELOXITAN oxaliplatin None. J9020 ELSPAR asparaginase injection None. J3380 ENTYVIO vedolizumab Yes, through Navitus. Restricted to Gastroenterology specialists with ENTYVIO (vedolizumab) J9055 ERBITUX cetuximab None. J7323 EUFLEXXA sodium hyaluronate, 1% None. Synvisc, Synvisc One preferred products J0180 FABRYZYME agalsidase Yes, through Navitus FABRAZYME (agalsidase) J3490 FASENRA benralizumab Yes, through Navitus. Restricted to Pulmonology, Allergy, or Immunology specialists with FASENRA (benralizumab) J9395 FASLODEX fulvestrant None. J3010 FENTANYL fentanyl citrate None. J1572 FLEBOGAMMA, IMMUNNE GLOBULIN, IVIG flebogamma Yes, through Navitus Immune Globulin J1325 FLOLAN epoprostenol sodium Yes, through Navitus. Restricted to cardiology or pulmonology specialists with prior authorization through Navitus FLOLAN (epoprostenol sodium) J9185 FLUDARA fludarabine phosphate None. Page 3 of 10
4 J1645 FRAGMIN dalteparin sodium None. J1569 J1561 GAMMAGARD, IVIG, IMMUNE GLOBULIN GAMUNEX, IVIG, IMMUNE GLOBULIN J9301 GAZYVA obinutuzumab immune globulin, (gammagard liquid) Yes, through Navitus Immune Globulin gamunex injection Yes, through Navitus Immune Globulin J9201 GEMZAR gemcitabine hcl None. Cover generic only. Yes, through Navitus. Restricted to Oncologists with GAZYVA (obinutuzumab) J9179 HALAVIN eribulin None. J1631 HALDOL haloperidol None. J1270 HECTOROL doxercalciferol None. J9355 HERCEPTIN trastuzumab injection Yes, through Navitus. Restricted to Oncology specialists with HERCEPTIN (trastuzumab injection) J1559 HIZENTRA, IMMUNE GLOBULIN immune globulin (hizentra) Yes, through Navitus Immune Globulin J9351 HYCAMTIN topotecan Yes, through Navitus. Restricted to Oncologists with HYCAMTIN (topotecan) J1170 HYDROPMORPHONE hydromorphone hci None. J7313 ILUVIEN fluocinolone acetonide intravitreal implant J3590 IMFINZI durvalumab Yes, through Navitus. Restricted to retinal and ophthalmology specialists with Not covered. Exception to Coverage Request required and restricted to specialty provider for condition. Use standard Exception to Coverage PA form and send to Prevea360 Health Plan Utilization Management Dept Fax (608) ILUVIEN (fluocinolone acetonide intravitreal implant) Exception to Coverage PA form J3030 IMITREX sumatriptan succinate None. J7307 IMPLANON etonogestrel implant system None. J1790 INAPSINE droperidol None. Page 4 of 10
5 Q5103 INFLECTRA - not preferred infliximab-dyyb Effective 10/1/17: Yes, through Navitus after failed trial of RENFLEXIS. Restricted to dermatology, rheumatology, or gastroenterology specialists with authorization Infliximab infusions J9214 INTRON-A interferon alfa-2b inj None. J1335 INVANZ ertapenem injection None. J1750 IRON iron dextran None. J1756 IRON iron sucrose, 1 mg None. J1566 IVIG, IMMUNE GLOBULIN immune globulin, powder Yes, through Navitus Immune Globulin J3301 KENALOG triamcinolone acet inj None. J3303 KENALOG, ARISTACORT triamcinolone None. J9271 KEYTRUDA pembrolizumab Yes, through Navitus. Limited to an oncologist with KEYTRUDA (pembrolizumab) J2805 KINEVAC sincalide injection None. J1626 KYTRIL granisetron None. J9285 LARTRUVO olaratumab J0202 LEMTRADA alemtuzumab Yes, through Navitus. Limited to Oncology with Yes, through Navitus. Limited to Neurology with LARTRUVO (olaratumab) LEMTRADA (alemtuzumab) J0640 LEUCOVORIN leucovorin calcium None. J7308 LEVULAN aminolevulinic acid None. J2060 LORAZEPAM lorazepam 2mg None. J1650 LOVENOX enoxaparin sodium None. Also covered under pharmacy benefit J2778 LUCENTIS ranibizumab None. Page 5 of 10
6 J1950 LUPRON leuprolide acetate /3.75 mg None. J9217 LUPRON DEPOT leuprolide acetate(for depot suspension) 7.5mg None. J1030 MEDROL methylprednisolone acetate 40 mg None. J9209 MESNEX mesna None. J9250 METHOTREXATE methotrexate None. J7302 MIRENA IMPLANT levonorgestrel iu contraception None. J2270 MORPHINE SULFATE morphine sulfate None. J9280 MUTAMYCIN, MITOSOL mitomycin None. J9300 MYLOTARG gemtuzumab ozogamicin J0587 MYOBLOC rimabotulinumtoxinb Not covered. Exception to Coverage Request required and restricted to specialty provider for condition. Use standard Exception to Coverage PA form and send to Prevea360 Health Plan Utilization Management Dept. Fax (608) Yes, through Prevea360 Health Plan Quality and Care Management Exception to Coverage PA form Botulinum Toxin J2310 NARCAN naloxone None. J9390 NAVELBINE vinorelbine tartrate None. J2505 NEULASTA pegfilgrastrim Yes, through Navitus. Restricted to oncology or hematology specialists with authorization NEULASTA (pegfilgrastim) Also covered on drug formulary. J1440 NEUPOGEN filgrastim None. Also covered on drug formulary. J2300 NUBAIN nalbuphine None. J2182 NUCALA mepolizumab J2350 OCREVUS ocrelizumab Yes, through Navitus. Restricted to Pulmonology, Allergy, and Immunology specialists with Yes, through Navitus. Restricted to neurology specialists with NUCALA (mepolizumab) OCREVUS (ocrelizumab) Page 6 of 10
7 J0129 ORENCIA I.V. abatacept Yes, through Navitus. Limited to Rheumatology with SQ version covered on drug formulary. ORENCIA (abatacept) J7324 ORTHOVISC hyaluronan or derivative None. Synvisc, Synvisc One preferred products J7312 OZURDEX dexamethasone intravitreal implant Not required. Restricted to retinal and ophthalmology specialists. OZURDEX (dexamethasone intravitreal implant) J9045 PARAPLATIN carboplatin None. J9306 PERJETA pertuzumab J1459 PRIVIGEN, IVIG, IMMUNE GLOBULIN Yes, through Navitus. Restricted to oncology or hematology specialists with authorization PERJETA (pertuzumab) privigen Yes, through Navitus Immune Globulin J0885 PROCRIT, EPOGEN epoetin alfa, (for non-esrd use) Prior authorization not needed for plan Infectious Disease, Hematology, Nephrology and Oncology clinicians. All others prior authorize through Navitus. EPOGEN, PROCRIT (epoetin alpha) J2675 PROGESTERONE, 17-HP, MAKENA progesterone None. J0897 PROLIA, XGEVA denosumab J3490 RADICAVA edaravone Yes, through Navitus. Restricted to Oncology, Rheumatology, Internal Medicine, or Endocrinology specialists with Yes, prior authorization required through Navitus. Please refer to the drug policy. PROLIA, XGEVA (denosumab) RADACAVA (edaravone) J3488 RECLAST zoledronic acid None. J1745 REMICADE - not preferred infliximab J3285 REMODULIN IV treprostinil Effective 10/1/17: Yes, through Navitus after failed trial of RENFLEXIS. Restricted to dermatology, rheumatology, or gastroenterology specialists with authorization Yes, through Navitus. Restricted to cardiology or pulmonology specialists with authorization Infliximab infusions REMODULIN (treprostinil) Q5104 RENFLEXIS - preferred infliximab product infliximab-abda Yes, through Navitus. Restricted to dermatology, rheumatology, or gastroenterology specialists with authorization Infliximab infusions J2794 RISPERDAL CONSTA risperidone, long acting None. Page 7 of 10
8 J9310 (Rituxan) J3490 (Rituxan Hycela) RITUXAN, RITUXAN HYCELA rituximab, rituximab and hyaluronidase human Yes, through Navitus. For Rituxan, restricted to rheumatology, transplant, hematology, neurology and oncology specialists with For HYCELA ONLY, restricted to oncology specialists with RITUXAN (rituximab) J0636 ROCALTROL, CALCIJEX calcitriol per 0.1 mcg None. J0696 ROCEPHIN ceftriaxone None. J2353 SANDOSTATIN octreotide Yes, through Navitus. Limited to (prescribed by or in consultation with an) endocrinologist or oncologist with SANDOSTATIN (octreotide) J1602 SIMPONI ARIA (IV only) golimumab J1300 SOLIRIS eculizumab J2326 SPINRAZA nusinersen Yes, through Navitus. Limited to rheumatology or gastroenterology specialists with Yes, through Navitus. Limited to nephrology, hematology or transplant specialists Yes, through Navitus. Limited to neurology specialists with expertise in SMA treatment. SIMPONI ARIA and SIMPONI SOLIRIS (eculizumab) SPINRAZA (nusinersen) J3358 STELARA IV ustekinumab Yes, through Navitus. Limited to rheumatology, gastroenterology, or dermatology specialists with SQ version (J3357) not covered through medical benefit and separate authorization request for the SQ version must be obtained through Navitus. STELARA (usetkinumab) J3590 STRENSIQ asfotase alfa Yes, through Navitus. Limited to Endocrinology with STRENSIQ (asfotase alfa) SYNAGIS palivizumab Yes, through Navitus SYNAGIS (palivizumab) J7321 SYNVISC, SYNVISC One hyaluronan or derivative (hyalgan, supartz, synvisc, euflexxa) None. Synvisc, Synvisc One preferred products J9265 TAXOL paclitaxel None. J9171 TAXOTERE doxetaxel None. Cover generic only. Page 8 of 10
9 J9022 TECENTRIQ atezolizumab Yes, through Navitus. Restricted to oncologists with authorization TECENTRIQ (atezolizumab) J1070 TESTOSTERONE testosterone cypionate None. J1885 TORADOL ketorolac tromethamine None. J9033 TREANDA bendamustine None. J2323 TYSABRI natalizumab injection Yes, through Navitus. Restricted to neurology or gastroenterology specialists with authorization TYSABRI (natalizumab) J9357 VALSTAR valrubicin injection None. J3370 VANCOCIN vancomycin None. J9303 VECTIBIX panitumumab Yes, through Navitus. Restricted to oncology specialists with authorization VECTIBIX (panitumumab) J9041 VELCADE bortezomib None. J9181 VEPESID etoposide None. J2250 VERSED midazolam hydrochloride None. J9025 VIDAZA azacitidine None. J9360 VINBLASTINE vinblastine sulfate None. J9370 VINCRISTINE, ONCOVIN vincristine sulfate None. J3420 VITAMIN B12 vitamin b12 cyanocobalamin up to 1000mcg None. J2315 VIVITROL naltrexone Yes, through Navitus. VIVITROL (naltrexone) J0588 XEOMIN incobotulinumtoxina J2357 XOLAIR omalizumab, 5mg Yes, through Prevea360 Health Plan Quality and Care Management Yes, through Navitus. Restricted to allergy, pulmonology, or dermatology specialists with authorization Botulinum Toxin XOLAIR (omalizumab) Page 9 of 10
10 J9228 YERVOY ipilimumab Effective 10/1/17: Yes, through Navitus. Restricted to oncology or hematology specialists with YERVOY (ipilimumab) J2501 ZEMPLAR paricalcitol None. J0565 ZINPLAVA bezlotoxumab Yes, through Navitus. Restricted to infectious disease or gastroenterology specialists with authorization ZINPLAVA (bezlotoxumab) J2405 ZOFRAN ondansetron None. J9202 ZOLADEX goserelin acetate implant None. J3489 ZOMETA zoledronic acid, 1 mg None. Notes: J3590 and J3490 are miscellaneous codes used for drugs that do not have a J code assigned by the FDA. New drugs may take between months to get a J code assigned These drugs are all medical injectable drugs, and are not listed on the Prevea360 Health Plan drug formulary. The on-line formulary only lists drugs covered by the pharmacy benefit. Any drug submitted under either J3590 or J3490 with a cost of $750 or greater will be reviewed post-claim by Prevea360 Health Plan Medical Review staff. It is recommended that any use of the miscellaneous codes be pre-approved ahead of time through Prevea360 Health Plan Utilization Management, especially for off-label uses from FDA indications. This list is non-inclusive, and lists only the top drugs by frequency. More than 1/3 of these drugs are used in cancer treatment. There are claim specific (Cotiviti) edits for many of these drugs. The edits limit the uses of these drugs to approved indications and dosages. In addition, Metavance has payment restrictions consistent with Prevea360 Health Plan Medical or Drug Policies. Page 10 of 10
Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
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Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List Code Drug Name Effective and/or Term Date J0129 Injection, abatacept (Orencia ), 10 mg J0178 Injection, aflibercept (Eylea
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PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H2020 96116
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PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H2020 96116 96112 96113 96121 96130 96131
SPECIALTY PHARMACY Master Clinical Drug List
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PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM) 500 MG $ J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA) 100 MG $14.364
G0333 INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.470 J0285 INJECTION, AMPHOTERICIN B 50 MG $10.280 J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX 10 MG $21.850 J0288
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G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.068 J0285 INJECTION, AMPHOTERICIN B 50 MG $32.987 J0287 INJECTION,
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G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.048 J0285 INJECTION, AMPHOTERICIN B 50 MG $31.668 J0287 INJECTION,
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