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Injectable Drugs Requiring Prior Authorization
All plans
Effective JULY 1, 2008
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Click the drug name
to get the PA form
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Code
|
Benefit
|
Use
|
| Acthar (corticotrophin) |
J0800
|
Medical
|
Up to 40 units; treatment for infantile spasms
Length of initial authorization: 2 weeks
Length of continuation authorization: 4 weeks
|
| Amiveve (alefacept)2 |
J0215
|
Medical
|
Per 10mg; biologic treatment for moderate to severe chronic plaque
psoriasis
Length of initial authorization: 3 months
Length of continuation authorization: 1 year
Two courses of therapy must be separated by at least 3 months
|
Aloxi (palonosetron)
|
J2469
|
Medical
|
Per 25 mg; antiemetic; PA required ONLY for home infusion providers
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Anzemet (dolasetron)
|
J1260
|
Medical
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Per 10 mg; antiemetic; PA required ONLY for home infusion providers
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Aralast (alpha 1 proteinase inhibitor - human)
|
J0256
|
Medical
|
Alpha-antitrypsin deficiency
|
| Boniva (ibandronate sodium) |
J1740
|
Medical
|
Injection 1 mg for treatment of osteoporosis
Length of authorization: 2 years (given one injection every 3 months)
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| Botox (Botulinum toxin type A)1 |
J0585
|
Medical
|
Per unit, for various neuro-muscular uses: see medical policy for covered
conditions
Length of authorization: 1 year (given one injection every 3 months)
Injections must be separated by at least 90 days
|
| Enbrel (etanercept)3 |
J1438
|
Pharmacy
|
Treatment of rheumatoid arthritis, juvenile RA, ankylosing spondylosis, plaque
psoriasis, psoriatic arthritis, and ankylosing spondylitis
Length of initial authorization: 3 months
Length of continuation authorization: 1 year (3 months for plaque psoriasis)
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| Erbitux (cetuximab) |
J9055
|
Medical
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Treatment of advanced metastatic colorectal cancer and head and neck cancer
Length of authorization: 4 injections
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Fabrazyme
(agalsidase beta)
|
J0180
|
Medical
|
Treatment of Fabry disease
Length of authorization: 1 year
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| Forteo (teriparatide)2,3 |
J3110
|
Pharmacy
|
Treatment of osteoporosis
Length of authorization: 2 years
|
Human growth hormone3:
Preferred:
Norditropin
Nutropin
Nutropin AQ
Other:
Humatrope
Saizen
Genotropin
Serostim
Zorptive (somatropin)3
Protropin (somatrem)
|
J2941
J2940
|
Pharmacy
|
Per 1 mg; human growth hormone (HGH)
Length of initial authorization: 1 year
Authorization of a non-preferred agent requires a clinical failure of a preferred agent
|
| Humira (adalimumab)2,3 |
J0135
|
Pharmacy
|
Treatment of rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, Crohn's disease, and plaque psoriasis
Length of initial authorization: 3 months
Length of continuation authorization: 1 year (3 months for plaque psoriasis)
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| Hyaluronic acid derivatives4 |
J7321 |
Medical |
Hyalgan or Supartz: Treatment of osteoarthritis of the knee(s)
Length of authorization: 3-5 injections
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| J7322 |
Medical |
Synvisc: Treatment of osteoarthritis of the knee(s)
Length of authorization: 3-5 injections |
| J7323 |
Medical |
Euflexxa: Treatment of osteoarthritis of the knee(s)
Length of authorization: 3-5 injections |
| J7324 |
Medical |
Orthovisc: Treatment of osteoarthritis of the knee(s)
Length of authorization: 3-5 injections |
Increlex
|
J2170
|
Medical
|
Treatment of insulin-like growth factor-1 deficiency
Length of authorization: 1 year
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IVIG (immune globulin) - various brand names
|
J1561
|
Medical
|
Gamunex |
|
J1566
|
Immune globulin, lyophilized (e.g., powder), 500 mg IV |
|
J1568
|
Injection, immune globulin (Octagam), intravenous, non-lyphilized (e.g. liquid), 500 mg |
|
J1569
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Gammagard liquid |
|
J1572
|
Flebogamma |
|
90283
|
Immune globulin, 100 mg subcutaneous |
|
Q4097
|
Privigen |
|
J1562/90284
|
Immune globulin (SC1g), 100 mg, subcutaneous |
| Kineret (anakinra)3 |
J3490
|
Pharmacy
|
For treatment of moderate to severe symptoms of rheumatoid
arthritis
Length of initial authorization: 3 months
Length of continuation authorization: 1 year
|
Kytril
|
J1626
|
Medical
|
Per 100 mcg; antiemetic; PA required ONLY for home infusion provider |
Lupron Depot
(leuprolide acetate) |
J91950
|
Medical
|
Injectin, leuprolide acetate (for depot suspension), per 3.75 mg
Length of authorization: 1 year
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|
J9217
|
Leuprolide acetate (for depot suspension), 7.5 mg |
| Myobloc (Botulinum toxin type B)1 |
J0587
|
Medical
|
Per 100 units; for treatment of cervical dystonia. See medical policy
Length of authorization: 1 year, given as 1 injection every 3 months
Injections must be separated by at least 90 days
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Orencia (abatacept)
|
J0129
|
Medical
|
For treatment of moderate to severe symptoms of rheumatoid
arthritis
Length of initial authorization: 3 months
Length of continuation authorization: 1 year
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| Pegasys (interferon alpha 2a)3 |
S0145
|
Pharmacy
|
Hepatitis C
Length of initial authorization: 3 months
Length of continuation authorization: 3-9 months (dependent on genotype)
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| PEG-Intron (interferon alpha 2b)3 |
S0146
|
Pharmacy
|
Hepatitis C
Length of initial authorization: 3 months
Length of continuation authorization: 3-9 months (dependent on genotype)
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| Prolastin (alpha 1 proteinase inhibitor) |
J0256
|
Medical
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Alpha-antitrypsin deficiency |
| Raptiva (efalizumab)3 |
S0162
|
Pharmacy
|
Per 125 mg; treatment of plaque psoriasis
Length of initial authorization: 3 months
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| Reclast (seloedronic acig) |
J3488
|
Medical
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Per 1 mg; treatment of osteoporosis
Length of authorization: 2 years, given as 1 infusion per year
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Remicade (infliximab)
|
J1745
|
Medical
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Per 10 mg; for treatment of rheumatoid arthritis, ankylosing spondylosis, Crohn's disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis
Length of initial authorization: 14 weeks
Length of continuation authorization: 1 year (3 months for psoriasis)
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Remodulin (treprostinil sodium)
|
J3285
|
Medical
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Per 1 mg; for treatment of pulmonary hypertension
Length of initial authorization: 3 months
Length of continuation authorization: 1 year
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Synagis (palvizumab)
|
90378 (IM)
90379 (IV)
J1565 (IV)
|
Medical
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Immune globulin for respiratory syncytial virus (RSV)
Length of authorization: 5 infusions (given monthly November - March)
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Tysabri (natalizumab)
|
J2323
|
Medical
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Per 1 mg; for treatment of multiple sclerosis
Length of authorization: Indefinite
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Vectibix (panitumumab)
|
J9303
|
Medical
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Treatment of advanced metastatic colorectal cancer
Length of authorization: 4 injections
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| Xolair (omalizumab)2 |
J2357
|
Medical
or
Pharmacy
|
Anti-IgE therapy for treating moderate to severe allergic asthma
Length of initial authorization: 6 months
Length of continuation authorization: 1 year
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Zevalin (ibritumomab tiuxetan)
|
A9522
A9523
|
Medical
|
Radioimmunotherapy; indicated for the treatment of relapsed or
refractory low-grade, follicular, or transformed B-cell non-Hodgkin's
lymphoma (NHL)
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