Abraxane J9264 Provider ONCOLOGY None NO Actemra J3262 Provider ARTHRITIS PA - all YES Acthar HP Gel J0800 Prov/Self Med/Pharm ENDOCRINE/METABOLIC PA - all YES Adagen J2504 Provider ENZYME DISORDERS None NO Adcetris J9042 Provider ONCOLOGY PA - Misc YES Aldurazyme J1931 Provider ENZYME DISORDERS INV/ COS NO Alferon N J9215 Provider INTERFERONS None NO Alimta J9305 Provider ONCOLOGY PA - all YES Amevive J0215 Provider PSORIASIS PA - all YES Aralast NP J0256 Provider PANICINAR EMPHYSEMA INV/ COS NO J0881 J0882 Self/Prov Pharm/Med BLOOD MODIFIER - ESF PA - all YES Aranesp Arranon J9261 Provider ONCOLOGY None NO Arzerra J9302 Provider ONCOLOGY PA - all YES Avastin J9035 Provider ONCOLOGY PA - all YES Benlysta J0490 Provider LUPUS PA - all YES Berinert J0597 Self/Prov Pharm/Med C1 INHIBITOR PA - all YES Botox J0585 Provider MUSCLE SPASM INV/ COS NO Campath J9010 Provider ONCOLOGY INV/ COS NO Camptosar J9206 Provider ONCOLOGY None NO Cerezyme J7186 Provider GAUCHER'S DISEASE INV/ COS NO Cimzia Vials J0718 Provider CROHN'S DISEASE PA - all YES Cinryze J0598 Self/Prov Pharm/Med C1 Inhibitor PA - all YES Cytovene IV J1570 Provider Anti-Viral None NO Dacogen J0894 Provider ONCOLOGY None NO Dysport J0586 Provider MUSCLE SPASM INV/ COS NO Elaprase J1743 Provider ENZYME DISORDERS None NO Elelyso J8499 Provider GAUCHER'S DISEASE PA-Misc YES Eligard IM J9217 Self/Prov Pharm/Med GYN/PROSTATE ONC None NO Eloxatin J9263 Provider ONCOLOGY None NO Epogen J0885 J0886 Q4081 Self/Prov Pharm/Med BLOOD MODIFIER - ESF PA - all YES March 25, 2013 Page 1 of 6
epoprostenol (Flolan, Veletri) J1325 Self/Prov Pharm/Med PULMONARY HTN PA - all YES epoprostenol (Flolan) diluent S0155 Self/Prov Pharm/Med PULMONARY HTN PA - all YES Erbitux J9055 Provider ONCOLOGY PA - all YES Erwinaze J9019 Provider ONCOLOGY PA - all YES Euflexxa J7323 Provider ARTHRITIS INV/ COS NO J0178 Q4026 Provider MACULAR DEGENERATION None NO Eylea Fabrazyme J0180 Provider ENZYME DISORDERS INV/ COS NO Factor VIIa - NovoSeven RT J7189 Self/Prov Pharm/Med ANTI-HEMOPHILIC FACTOR INV/ COS NO Firmagon J9155 Provider ONCOLOGY None NO Folotyn J9307 Provider ONCOLOGY PA - all YES Gammagard Liquid J1569 Self/Prov Pharm/Med IMMUNE GLOBULINS INV/ COS NO Gamunex C 90284 Self/Prov Pharm/Med IMMUNE GLOBULINS INV/ COS NO Gemzar J9201 Provider ONCOLOGY None NO Halaven J9179 Provider ONCOLOGY PA - all YES Herceptin J9355 Provider ONCOLOGY None NO Hyalgan J7321 Provider ARTHRITIS INV/ COS NO Hycamtin injection J9351 Self/Prov Pharm/Med ONCOLOGY None NO Hylenex (hyaluronate) J3473 Provider ARTHRITIS INV/ COS NO Ilaris J0638 Provider MONOCLONAL ANTIBODY None NO Immune Globulin - CytoGam Immune Globulin - IM J0850 90291 Provider Immune Globulins None NO J1460 J1560 90281 90371 90389 Provider Immune Globulins INV/ COS NO March 25, 2013 Page 2 of 6
Immune Globulin - IV SPECIALTY PHARMACY J1459 J1599 J1561 J1566 J1568 J1569 J1572 J1573 90283 Provider Immune Globulins INV/ COS NO J2788 J2790 J2791 J2792 90384 90385 90386 Provider Immune Globulins INV/ COS NO Immune Globulin - RhoD Intron A IV J9214 Provider INTERFERONS None NO Istodax J9315 Provider ONCOLOGY PA - all YES Ixempra J9207 Provider ONCOLOGY None NO Jetrea J3590 Provider OPTHAMOLOGY PA-Misc YES Jevtana J9043 Provider ONCOLOGY PA - all YES Kadcyla J3490 Provider ONCOLOGY PA-Misc YES Krystexxa J2507 Provider GOUT PA - all YES Kyprolis J9999 Provider ONCOLOGY PA-Misc YES Leukine J2820 Provider BLOOD MODIFIER - CSF None NO Lucentis J2778 Provider OPTHAMOLOGY None NO Lumizyme J0221 Provider POMPE'S DISEASE INV/ COS NO J1950 Lupron Depot IM J9217 Provider GYN/PROSTATE ONC INV/ COS NO Macugen J2503 Provider OPHTHAMOLOGY None NO J1725 Makena J3490 Provider HORMONE THERAPY None NO Marqibo J9999 Provider ONCOLOGY PA-Misc YES March 25, 2013 Page 3 of 6
Mirena J7302 Provider CONTRACEPTIVES None NO Mozobil J2562 Self/Prov Pharm/Med HEMATOPOIETIC None NO Myobloc J0587 Provider MUSCLE SPASM INV/ COS NO Myozyme J0220 Provider POMPE'S DISEASE INV/ COS NO Naglazyme J1458 Provider ENZYME DISORDERS INV/ COS NO Neulasta J2505 Self/Prov Pharm/Med BLOOD MODIFIER - CSF None NO Neumega J2355 Self/Prov Pharm/Med BLOOD MODIFIER - PSF None NO Neupogen J1440 J1441 Self/Prov Pharm/Med BLOOD MODIFIER - CSF None NO Nexplanon J7307 Provider CONTRACEPTIVES None NO Novantrone (mitoxantrone) J9293 Provider MULTIPLE SCLEROSIS None NO Nplate J2796 Provider THROBOPOIETIN RECEPTOR AGONIST None NO J0890 Q2047 Provider RENAL FAILURE PA - all YES Omontys Orencia J0129 Provider ARTHRITIS PA - all YES Orthovisc J7324 Provider ARTHRITIS INV/ COS NO Ozurdex J7312 Provider MACULAR EDEMA None NO Perjeta J9999 Provider ONCOLOGY PA-Misc YES Prialt J2278 Provider ANALGESIC None NO J0885 J0886 Q4081 Self/Prov Pharm/Med BLOOD MODIFIER - ESF PA - all YES Procrit Proleukin J9015 Provider ONCOLOGY None NO Prolia J0897 Provider OSTEOPOROSIS PA - all YES Provenge (limited) Q2043 Provider ONCOLOGY PA - all YES Qutenza J7335 Provider NEUROPATHIC PAIN None NO Reclast J3488 Provider OSTEOPOROSIS None NO Remicade J1745 Provider ARTHRITIS PA - all YES Remodulin (Curascript, Accredo, J3285 Caremark) Self/Prov Pharm/Med PULMONARY HTN PA - all YES Retisert J7311 Provider OPTHAMOLOGY None NO March 25, 2013 Page 4 of 6
J7178 J1680 BLEEDING-FIBRINOGEN RiaSTAP Q2045 Provider DEFICIENCY None NO Risperdal Consta J2794 Provider SCHIZOPHRENIA None NO Rituxan J9310 Provider ONCOLOGY PA - all YES Sandostatin LAR J2353 Provider ONCOLOGY None NO Skyla J3490 Provider CONTRACEPTIVES None NO Soliris J1300 Provider BLOOD MODIFIER PA - all YES Somatuline J1930 Provider ENDOCRINE/METABOLIC None NO Stelara J3357 Provider PSORIASIS PA - all YES Supartz J7321 Provider ARTHRITIS INV/ COS NO Supprelin J9226 Provider ENDOCRINE/METABOLIC None NO Synagis 90378 Provider RSV PA - all YES Synribo J9999 Provider ONCOLOGY PA-Misc YES Synvisc J7325 Provider ARTHRITIS INV/ COS NO Synvisc One J7325 Provider ARTHRITIS INV/ COS NO Temodar Inj J9328 Provider CHEMOTHERAPY PO PA - all YES Thyrogen J3240 Provider ONCOLOGY None NO Torisel J9330 Provider ONCOLOGY None NO Treanda J9033 Provider ONCOLOGY PA - all YES Trelstar J3315 Provider GYN/PROSTATE ONC None NO Trisenox J9017 Provider ONCOLOGY None NO Tysabri J2323 Provider MULTIPLE SCLEROSIS PA - all YES Vantas J9225 Provider GYN/PROSTATE ONC None NO Vectibix J9303 Provider ONCOLOGY PA - all YES Velcade J9041 Provider ONCOLOGY PA - all YES Veletri J1325 Self/Prov Pharm/Med PULMONARY HTN PA - all YES Vidaza J9025 Provider ONCOLOGY INV/ COS NO Vistide J0740 Provider ONCOLOGY None NO Visudyne J3396 Provider PHOTODYNAMIC THERAPY INV/ COS NO Vivitrol J2315 Provider OPIOID ANTAGONIST None NO Vpriv J3385 Provider GAUCHER'S DISEASE INV/ COS NO Xeomin J0588 Provider MUSCLE SPASM INV/ COS NO March 25, 2013 Page 5 of 6
Xgeva J0897 Provider OSTEOPOROSIS PA - all YES DUPUYTREN'S CONTRACTURE INV/ COS NO Xiaflex J0775 Provider Xolair J2357 Provider ASTHMA PA - all YES Yervoy J9228 Provider ONCOLOGY PA - all YES Zaltrap J9999 Provider ONCOLOGY PA-Misc YES Zemaira ( Accredo & Coram) J0256 Provider PANICINAR EMPHYSEMA INV/ COS NO Zoladex J9202 Provider GYN/PROSTATE ONC None NO Zometa J3487 Provider ONCOLOGY None NO Drugs & Codes in red are the newest changes to the specialty list Legend None - Indicates policies are implemented but do not have configuration INV/COS if P/D - Claim will deny investigational or cosmetic if a procedure/diagnosis conflict exists PA-All - Requires a orization, may be for all providers or only certain types of providers PA-Misc - Requires a orization for miscellaneous code. This PA will be re-evaluated once a specific Procedure becomes available. Miscellaneous Codes: J3490 Unclassified Drugs J3590 Unclassified Biologics J7199 Hemophilia Clotting Factor, Not Otherwise Classified J7699 NOC Drugs, Inhalation Solution istered thru DME J8499 Oral Drug, Non Chemo J8999 Oral Drug, Chemo J9999 Not Otherwise Classified, Antineoplastic Drug March 25, 2013 Page 6 of 6