Injectable drug list

Notes:

  • Emergency room, skilled nursing facility or inpatient use of these medications does not require prior authorization.
  • All medications billed with miscellaneous codes will require authorization if line charge is greater than $500.
  • Click a medication name to open its prior authorization/medical necessity form.
  • Drug listings in boldface indicate the drug must be ordered through a specialty pharmacy.
    Go to the specialty pharmacy fax order form.
  • Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
Injectable drugs requiring prior authorization all plans
Updated November 2016
Click to get the PA form Code Benefit Use Criteria for coverage
Actemra® (tocolizumab)6
Commercial & Medicaid or Medicare
J3262 Medical Rheumatoid arthritis

Moderate to severe rheumatoid arthritis in adults

Trial of at least one self-injectable anti-TNF

Negative TB test (must be done yearly)

Pretreatment labs completed and within normal limits (CBC with diff, LFTs, Lipid panel)

Patient must not be receiving Actemra in combination with and other biologic drug

Acthar® (corticotrophin)
Commercial or Medicare forms

J0800 Pharmacy

Up to 40 units; treatment for infantile spasms

Length of initial authorization: 2 weeks

Length of continuation authorization: 4 weeks

Infantile spasms (age 2 years and younger)

Acute exacerbation of multiple sclerosis after prior use of corticosteroids and plasma exchange, and in patients currently treated with immunomodulatory drug

Adcetris® (brentuximab)
Commercial and Medicaid only
J9042 Medical Treatment of Hodgkins lymphoma and anaplastic large cell lymphoma One of the following diagnoses:
  • Adult patients with Hodgkins lymphoma after prior use of autologous stem cell transplant (ASCT) or after prior use of at least two prior multi-agent chemotherapy regimens.
  • Adult patients with systemic anaplastic large cell lymphoma (ALCL) after prior use of at least one prior multi-agent chemotherapy regimen.
Aloxi (palonosetron) J2469 Medical Per 10 mg; antiemetic; PA required ONLY for home infusion providers
Amevive (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: 3 months

Two courses of therapy must be separated by at least 3 months

Diagnosis of chronic moderate-to-severe plaque psoriasis affecting >10% of BSA (unless hands, feet, head and neck, or genitalia)

Documented trial of one topical agent, one systemic treatment, and phototherapy

Anzemet (dolasetron)
Medicare Part B vs Part D form
J1260 Medical

Per 10 mg; antiemetic; PA required ONLY for home infusion providers

See PA form
Click to get the PA form Code Benefit Use Criteria for coverage

Aralast NP (alpha 1 proteinase inhibitor - human)
Commercial & Medicaid or Medicare

J0256 Medical Alpha-antitrypsin deficiency

Diagnosis of congenital alpha 1-antitrypsin deficiency

Clinically evident emphysema

FEV1 30-65% predicted

Serum AAT level < 11mM/L (< 60 mg/dL)

Arzerra (ofatumumab)
Commercial & Medicaid only
J9032 Medical Treatment of refractory CLL

Diagnosis of CLL

Prior use of fludarabine (Fludara) and alemtuzumab (Campath)

Avastin (bevacizumab) J3590*
C9257*
Medical No prior auth required.
Also comes in a formulation used to treat cancer as a chemotherapeutic agent (J9035).
Don't bill J9035 for ophthalmic indications.
Covered only when billed with the following ICD-10 diagnoses:
B39.4 Histoplasmosis capsulati, unspecified
B39.5 Histoplasmosis duboisii
B39.9 Histoplasmosis, unspecified
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.321 Diabetes mellitus due to underlying condition
with mild nonproliferative diabetic retinopathy with macular edema
E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with
B39.4 Histoplasmosis capsulati, unspecified
B39.5 Histoplasmosis duboisii
B39.9 Histoplasmosis, unspecified
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy
Aveed® (testosterone undeconoate)
Commercial or Medicare
J3145
Medical Treatment of hypogonadism

Patient is male

Patient is hypogonadal, as evidenced by both of the following: Clinical signs and symptoms consistent with androgen deficiency (requests for coverage to treat decreased libido with no other symptoms is not a covered benefit), and subnormal serum total testosterone concentration (lab results must be included or faxed with request)

Documentation of prior use with injectable testosterone (e.g. testosterone enanthate 150 to 200 mg every two weeks) for a minimum of two months

After a trial with injectable testosterone, must then first try Androgel or Axiron

Beleodaq®
Commercial & Medicaid or Medicare

J9032
Medical Treatment of relapsed or refractory peripheral T-cell lymphoma (PTCL)

Diagnosis of peripheral T cell lymphoma

Relapse or refractory after at least one first line chemotherapy regimen (e.g. CHOP or variation thereof)

Benlysta® (belimumab)
Commercial & Medicaid only
J0490 Medical Treatment of SLE

Active, auto-antibody positive SLE

Baseline SELENA-SLEDAI score of 6 or more

Free of severe nephritis, CNS manifestations, and chronic infections

Currently receiving standard therapy for at least 3 months

Not receiving any biologic therapy or intravenous cyclophosphamide

Blincyto®
Commercial & Medicaid or Medicare

J9039 Medical Per 1 mcg: Tx of Philadelphia chromosome-negative precursor B-cell acute lymphoblastic leukemia (B-cell ALL)

Must meet one of the following requirements:

  • Philadelphia chromosome-negative relapsed or refractory B-cell acute lymphoblastic leukemia
  • Philadelphia chromosome-positive acute lymphoblastic leukemia after first trying a tyrosine kinase inhibitor

Also:

  • Drug must be started in the hospital for initial treatment
  • When certified, each approval will be for 6 months.
Click to get the PA form Code Benefit Use Criteria for coverage
Boniva® (ibandronate sodium)
Commercial only
J1740 Medical

Injection 1 mg for treatment of osteoporosis

Diagnosis of postmenopausal osteoporosis (T-score ≤ -2.5)

Clinical trial of Fosamax, Actonel and Reclast

Coverage limited to 5 years in a lifetime combined with other bisphosphonate therapy unless patient is high risk

Botox1 (Botulinum toxin type A)
Commercial & Medicaid or Medicare 
J0585 Medical

Per unit, for various neuro-muscular uses: see prior authorization form for covered conditions

Length of authorization: 1 year (given one injection every 3 months)

Injections must be separated by at least 90 days

See PA forms for covered indications list

Cimzia® (certolizumab)
Commercial or Medicare 
J0717 Medical or Pharmacy

Per 1mg; treatment of moderate to severe Crohn's disease and rheumatoid arthritis

Medical coverage if administered by health professional

Pharmacy coverage if self-injected

Prior use of either Enbrel or Humira

Diagnosis of rheumatoid arthritis with prior use of at least one DMARD and prior use of either Enbrel or Humira

Diagnosis of Crohn's disease or ulcerative colitis with prior use of at least two of the following formulary alternatives: corticosteroids, sulfasalazine, osalazine, and mesalamine and prior use of Humira

Negative TB test (must be done yearly)

Cinqair® (reslizumab)
Commercial or Medicare
J3590*
C9481*
Medical Treatment of eosinophilic asthma

Must be age 18 or older

Must have eosinophilic asthma, confirmed by:

  • Sputum eosinophil count of 3% or higher, or
  • Asthma-related peripheral blood eosinophil count of 300 cells/mcL or higher

Must first try all of the following therapies:

  • High-dose inhaled corticosteroids for 3 months or longer;
  • Leukotriene receptor antagonists
Cyramza® (ramucirumab)
Commercial & Medicaid only
J9308
Medical Treatment of gastric cancer

Treatment of advanced gastric cancer, or

Gastro-esophageal junction adenocarcinoma

Dalvance® (dalbavancin)
Commercial only
J0875
Medical Treatment of acute bacterial skin and skin structure infections

Must be age 18 or older

Must fax a copy of culture and sensitivity results to Priority Health showing the patient's infection is not susceptible to alternative antibiotic treatments

Must be started in the hospital or other health care facility and will be continued in outpatient facility for treatment of acute bacterial skin and skin structure infection (ABSSSI)

Must have one of the following conditions:

  • Documented methicillin-resistant Staphylococcus aureus (MRSA) ABSSSI infection, or
  • Patient cannot tolerate or is resistant to other MRSA sensitive antibiotics
Duopa® (carbidopalevodorpa entral suspension)6
Commercial & Medicaid only
J7340 Medical Intestinal infusion for treatment of Parkinson's disease

Diagnosis of Parkinson's Disease

Must first try three other drug therapies, including:

  • Any oral carbidopa-levodopa formulation,
  • A dopamine agonist, and
  • One drug from another antiparkinsonian drug class, such as COMT inhibitors or MAO-B inhibitors
Click to get the PA form Code Benefit Use Criteria for coverage
Dysport® (botulinumtoxin A)1
Commercial & Medicaid or Medicare
J0586 Medical

Per 5 units, for various neuro-muscular uses: see prior authorization form for covered conditions

Length of authorization: 1 injection

Injections must be separated by at least 90 days

See PA form for covered indications list

Enbrel® (etanercept)3
Commercial & Medicaid or Medicare
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)

Diagnosis of rheumatoid arthritis, juvenile RA, ankylosing spondylosis, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis

Negative TB test (provided on an annual basis)

Prior use of DMARD (except ankylosing spondylitis and plaque psoriasis)

Ankylosing spondylitis requires prior use of at least 2 NSAIDs, intra-articular steroids, and sulfasalazine in patients with peripheral arthritis

Plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia) and a documented trial of one topical agent, one systemic treatment, and phototherapy

Entyvio® (vedolizumab)
Commercial & Medicaid only 
J3380 Medical Treatment of adult Crohn's disease & ulcerative colitis

Crohn's disease:

  • Must first try two of the following: corticosteroids, mesalamine, olsalazine, and sulfasalazine
  • Must first try Humira

Ulcerative colitis:

  • Must first try two of the following: 6-mercaptopurine (6-MP), azathioprine, balsalazide, corticosteroids, mesalamine, and sulfasalazine
  • Must first try Humira
Erbitux® (cetuximab)
Commercial & Medicaid or Medicare 
J9055 Medical

Treatment of advanced metastatic colorectal cancer and head and neck cancer

Length of authorization: 4 injections

Patient is 18 years of age

Diagnosis of metastatic colorectal cancer or squamous cell carcinoma of the head and neck

Documented KRAS negative mutation status for colorectal cancer

Used in combination with other therapy or as a single agent in members that have failed or been intolerant to other therapy

Click to get the PA form Code Benefit Use Criteria for coverage
Erwinaze® (asparaginase erwinia chrysanthemi)
Commercial & Medicaid only
J9019 Medical Treatment of acute lymphoblastic leukemia (ALL) Prior use or inadequate response to Elspar or Oncaspar
Extavia® (interferon beta 1b) J1830 Pharmacy Treatment of multiple sclerosis

Requires prior use of Copaxone

Requires prior use of Rebif and Avonex (unless nAb suspected)

Eylea® (aflibercept)6
Commercial & Medicaid only
J0178 Medical Treatment of age-related macular degeneration and macular edema following central retinal vein occlusion

Age-related macular degeneration requires prior use of Avastin

Auth for all lines of business except  Medicare (IJO7 / IJON / IJ2H)

Covered only when billed with the following ICD10 diagnoses:
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211 – E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.3311 – E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.3411 – E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.3511 – E083513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.3211 – E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.3311 – E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.3411 – E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.3511 – E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.3211 – E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.3311 – E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.3411 – E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3411 – E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3511 – E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.3211 – E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.3311 – E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.3411 – E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.3511 – E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.3211- E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.3311 – E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3411 – E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.3511 – E13.3513  Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
H34.8110-H34.8122 Central retinal vein occlusion
H34.8310-H34.8332 Tributary (branch) retinal vein occlusion,
H35.051 – H35.053 Retinal neovascularization, unspecified
H35.3210 – H35.3233  Exudative age-related macular degeneration
H35.81 Retinal edema

Fabrazyme® (agalsidase beta)Commercial & Medicaid only J0180 Medical

Treatment of Fabry disease

Length of authorization: 1 year

Diagnosis of Fabry disease
Firmagon® (degrelix) J9155 Medical Treatment of prostate cancer

Diagnosis of prostate cancer

Prior use of leuprolide (Lupron Depot), goserelin (Zoladex) or triptorelin (Trelstar Depot) with or without anti-androgen therapy for the first 30 days

Flolan® (epoprostenol)6
Commercial & Medicaid only
J1325 Medical Treatment of primary pulmonary hypertension Diagnosis of pulmonary arterial hypertension (PAH), WHO classification I
Click to get the PA form Code Benefit Use Criteria for coverage
Forteo® (teriparatide)2,3
Commercial & Medicaid or Medicare
J3110 Pharmacy

Treatment of osteoporosis

Length of authorization: 2 years

Diagnosis of postmenopausal osteoporosis in women or primary or hypogonadal osteoporosis in men

Clinical trial and failure with Fosamax (alendronate) and Actonel

Gattex® (teduglutide)
Commercial or Medicare
J3490
C9399
Pharmacy Treatment of short bowel syndrome

See PA forms for details

Gazyva® (obinutuzumab)
Commercial or Medicare
J9301 Medical Treatment of chronic lymphocytic leukemia

Must have chronic lymphocytic leukemia

Must be treatment naïve

Must be used in combination with Leukeran

Glassia® (alpha 1 proteinase inhibitor - human)
Commercial & Medicaid or Medicare
J0257 Medical Alpha-antitrypsin deficiency

Diagnosis of congenital alpha 1-antitrypsin deficiency

Clinically evident emphysema

FEV1 30-65% predicted

Serum AAT level < 11mM/L (< 60 mg/dL)

Human growth hormone3:
Commercial & Medicaid or Medicare

Preferred:
Norditropin

Other:
Nutropin
Nutropin AQ
Humatrope
Saizen
Genotropin
Serostim
Zorptive (somatropin)3
Protropin

J2941
J2940
(Protropin)
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

Pediatrics: Diagnosis of idiopathic growth hormone deficiency (requires submission of appropriate lab tests) or Turner's syndrome

Adults: Documented growth hormone deficiency and hypothalamic pituitary disease, history of cranial radiation, pituitary surgery, or continued treatment of childhood growth hormone deficiency

Humira® (adalimumab)2,3
Commercial & Medicaid or Medicare
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)

Diagnosis of rheumatoid arthritis, juvenile RA, ankylosing spondylosis, Crohn's disease, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis or ulcerative colitis

Negative TB test (provided on an annual basis)

Prior use of one or more DMARD (except Crohn's disease, ankylosing spondylitis and plaque psoriasis)

Crohn's disease and ulcerative colitis requires prior use of two or more conventional therapies

Ankylosing spondylitis requires prior use of at least 2 NSAIDs, intra-articular steroids, and sulfasalazine in patients with peripheral arthritis

Plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia) and a documented trial of one topical agent, one systemic treatment, AND phototherapy

Click to get the PA form Code Benefit Use Criteria for coverage

Hyaluronic acids4,6
Commercial only

Preferred: Euflexxa
(no PA required for Euflexxa)

J7323 Medical

Euflexxa: Treatment of osteoarthritis of the knee(s)

No PA required for Euflexxa

Diagnosis of osteoarthritis of the knee(s)

Clinical trial and failure of at least two other pharmacologic therapies (NSAIDs, COX-2 selective NSAIDs, acetaminophen, IA corticosteroids, tramadol)

Euflexxa is the preferred product. All other hyaluronic acid derivative products require prior use of Euflexxa.

Prior authorization is not required for Euflexxa

C9471
J7321
Medical

Hymovis

Hyalgan or Supartz: 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

J7325 Medical

Synvisc or Synvisc One: Treatment of osteoarthritis of the knee(s)

Length of authorization: 1-5 injections

J7326 Medical Gel-One: Treatment of osteoarthritis of the knee(s)
J7327 Medical Monovisc: Treatment of osteoarthritis of the knee(s)
J328 Medical Gel-Syn (0.1mg)
Q9980 Medical GelVisc (1mg)

Ilaris® (canakinumab)6
Commercial & Medicaid or Medicare

J0638 Medical

Treatment of Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS)

C-code billable by facility only

One of the following diagnoses: Cryopyrin-Associated Periodic Syndromes (CAPS): including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) in patients ≥ 4 years old.
Imlygic®(talimogene laherparepvec)
Commercial & Medicaid or Medicare
C9472
J9999*
Medical Intralesional, intranodal or subcutaneous treatment of cutaneous lesion -0 multiple melanoma

Must have unresectable melanoma with cutaneous, subcutaneous, or nodal lesions melanoma

Must first have surgery

Click to get the PA form Code Benefit Use Criteria for coverage
Increlex®
Commercial & Medicaid only
J2170 Pharmacy

Treatment of insulin-like growth factor-1 deficiency

Length of authorization: 1 year

Diagnosis of severe primary insulin-like growth factor-1 deficiency or growth hormone gene deletion who have developed neutralizing antibodies to GH

Must be evaluated by a pediatric endocrinologist

IVIG (immune globulin) - various brand names
Commercial, Medicaid or Medicare
J1561 Medical Gamunex See PA forms for coverage details
J1566 Immune globulin, lyophilized (e.g., powder), 500 mg IV
J1568 Injection, immune globulin (Octagam), intravenous, non-lyphilized (e.g. liquid), 500 mg
J1569 Gammagard liquid
J1599 Gammagard SD
J1572 Flebogamma
90283 Immune globulin, 100 mg subcutaneous
J1459 Privigen
J1562/90284 Vivaglobin (SC1g), 100 mg, subcutaneous
J1559 Hizentra
J1557 Gammaplex
J1556 Bivigam
J1575 HyQvia 
Click to get the PA form Code Benefit Use Criteria for coverage
Jetrea® (ocriplasmin) J7316 Medical Treatment of vitreomacular adhesion

No PA required. 

Covered only for H43.821 – H43.829, Vitreomacular adhesion

Jevtana® (carbazitaxel)
Commercial & Medicaid or Medicare

J9043 Medical Treatment of hormone-refractor metastatic prostate cancer

Diagnosis of hormone-refractory metastatic prostate cancer

Serum prostate-specific antigen (PSA) ≥ 5 ng/mL

Two sequential rising PSA levels obtained 2-3 weeks apart or other evidence of disease progression

Eastern Cooperative Oncology Group (ECOG) performance status of 0-2

Serum testosterone < 50 ng/dL

Jevtana will not be authorized for patients with any of the following:

  • Congestive heart failure
  • Myocardial infarction within the last 6 months
  • Uncontrolled cardiac arrhythmias, angina pectoris, and/or hypertension
  • ECOG performance status ≥ 3

Kadcyla® (ado-trastuzumab)6
Commercial & Medicaid or Medicare

J9354 Medical Metastatic breast cancer

Patient has a diagnosis of (HER2)-positive, metastatic breast cancer

Patient has previously received Herceptin® (trastuzumab) and a taxane, separately or in combination.

See PA forms for details

Keytruda® (pembrolizumab)6
Commercial & Medicaid or Medicare

J9271 Medical

Treatment of unresectable or metastatic melanoma

Prior use of Yervoy

Prior use of a BRAF inhibitor if BRAF V600 mutation positive

Kineret® (anakinra)3
Commercial or Medicare

J3590
J9999
Pharmacy

For treatment of moderate to severe symptoms of rheumatoid arthritis

Length of initial authorization: 3 months

Length of continuation authorization: 1 year

Diagnosis of moderate to severe rheumatoid arthritis

Negative TB test (provided on an annual basis)

Prior use of one or more DMARD

Prior use of Enbrel

Krystexxa® (pegloticase)
Commercial & Medicaid only
J2507 Medical

For treatment of chronic gout refractory to conventional therapy

Length of initial authorization: 3 months

Length of continuation authorization: 1 year

Symptomatic gout and has experienced three or more flares within the past 18 months

Patient has at least one gout tophus or has gouty arthritis

Prior use (at least 6 months) of conventional therapy

Continuation requires SUA level ≤ 6 mg/dL

Click to get the PA form Code Benefit Use Criteria for coverage

Kynamro® (mipomersen sod)3
Commercial & Medicaid or Medicare

J3490
C9399
Pharmacy Treatment of homozygous familial hypercholesterolemia

Diagnosis of homozygous familial hypercholesterolemia (HoFH)

Concurrent use of statin therapy at maximum available dose (e.g. atorvastatin 80mg or Crestor 40mg daily)

Concurrent use of Zetia

Concurrent or prior use of Niaspan

Concurrent or prior use of a bile acid sequestrant

History of one of the following, unless contraindicated:

  • LDL apheresis
  • Liver transplantation

Despite all of the above therapy (drugs, LDL aphresis and liver transplantation), the patient’s LDL is not at goal, defined as:

  • Greater than or equal to 200 mg/dL in patients without cardiovascular disease
  • Greater than or equal to 160 mg/dL in patients with established cardiovascular disease

Lemtrada®
Commercial or Medicare

J0202  Medical  Treatment of multiple sclerosis  
Lucentis® (ranibizumab)6
Commercial & Medicaid only
J2778 Medical Treatment of AMD and RVO

Prior use of Avastin (bevacizumab)

Auth required for all lines of business except Medicare

Covered only when billed with the following ICD10 diagnoses:

E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211–E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.3311–E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.3411– E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.3511- E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.3211-E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.3311-E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.3411- E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.3511- E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.3211- E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.3311- E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.3411- E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3511-E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.3411- E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.3511 E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.3211- E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.3211- E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.3311- E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3311- E13.3313  Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3411-E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.3511- E13.3513   Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
H34.8110-H34.8132 Central retinal vein occlusion
H34.8120 – H34.8122 Central retinal vein occlusion
H34.8310-H34.8332Tributary (branch) retinal vein occlusion
H35.051-H35.053 Retinal neovascularization, unspecified
H35.3210-H35.3233 Exudative age-related macular degeneration
H35.81 Retinal edema

 
 

Click to get the PA form Code Benefit Use Criteria for coverage
Macugen® (pegaptinib)6
Commercial & Medicaid only
J2503 Medical Treatment of AMD

Prior use of Avastin (bevacizumab)

PA for all lines of business except for Medicare 

Covered when billed with the following ICD10 diagnoses:

E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211-E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.3311-E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.3411-E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.3511-E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.3211-E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.3311-E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.3411-E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.3511-E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.3211-E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.3311-E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
severe nonproliferative diabetic retinopathy with macular edema
E10.3511-E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.3211-E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.3311-E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.3411-E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.3511-E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.3211-E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.3311-E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3411-E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.3511-E13.3513  Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
H34.8110-H34.8132 Central retinal vein occlusion
H35.3210-H35.3233 Exudative age-related macular degeneration

Makena® (hydroxyprogesterone caproate)6
Commercial & Medicaid only
J1725 Medical Prevention of preterm labor

Must be used to reduce the risk of preterm birth

Must be a singleton pregnancy

Woman must have a history of a prior spontaneous preterm birth of singleton pregnancy

The first weekly injection of Makena must be started on or after 16 weeks gestation, but before 27 weeks gestation

Makena must be stopped at 36 weeks, 6 days gestation or delivery, whichever comes first

Marqibo® (vincristine, liposome)6
Commercial & Medicaid only
J9371 Medical Medical treatment of acute lymphoblastic leukemia (ALL)

Diagnosis of acute lymphoblastic leukemia (ALL)

Patient's condition has relapsed two or more times or the patient has tried two other drugs and continues to have disease progression

Myobloc® (Botulinum toxin type B)1
Commercial & Medicaid  or Medicare
J0587 Medical

Per 100 units; for treatment of cervical dystonia. See prior authorization form.

Length of authorization: 1 year, given as 1 injection every 3 months

Injections must be separated by at least 90 days

See PA forms for covered indications list

Treatment for anal fissures and headache diagnoses require a clinical trial of conventional therapies

Nplate® (romiplostim)
Commercial or Medicare
J2796 Medical

For treatment of chronic immune (idiopathic) thrombocyctopenia (ITP)

Starting dose 1 mck/kg SC weekly. Median dose to achieve response: 2-3 mcg/kg weekly. (Max dose 10 mcg/kg weekly). Dose to achieve platelet count above 50 x 109/L (not to normal platelet levels).

Length of initial authorization: 4 injections

Length of continuation authorization: If platelet count increases to a level sufficient to avoid clinically important bleeding, approved for an additional 4 injections

Diagnosis of chronic immune (idiopathic) thrombocytopenic purpura (ITP)

Patient has had an insufficient response to corticosteroids, immunoglobulins or splenectomy

Current platelet count < 50 x 109/L with clinical risk of bleeding

Nucala® (mepolizumab)
Commercial & Medicaid or Medicare
C9399*
J3590*
Medical Subcutaneous injection for treatment of asthma

Must be age 12 or older

Must have eosinophilic asthma, confirmed by:

  • Sputum eosinophil count of 3% or higher, or
  • Asthma-related peripheral blood eosinophil count of at least 150 cells/mcL in the past 6 weeks
  • Asthma-related peripheral blood eosinophil count of at least 300 cells/mcL in the past 12 months

Must first try all of the following therapies:

  • High-dose inhaled corticosteroids for 3 months or longer; and
  • Leukotriene receptor antagonists

Must not currently use tobacco products

Nulojix® (belatacept)6
Commercial & Medicaid or Medicare
J0485 Medical For treatment of Hodgkins lymphoma and anaplastic large cell lymphoma

New kidney transplant (started Day 1 after transplant), given in combination with basiliximab induction, mycophenolate mofetil, and corticosteroids

Seropositive for Epstein-Barr virus (EBV)

Allergy or intolerance to tacrolimus and/or cyclosporine

Onivyde® (irinotecan HCl)
Commercial & Medicaid or Medicare
C9474
J9999*
Medical Treatment of pancreatic cancer The patient must use the drug for treatment of adenocarcinoma of pancreas, metastatic progressive disease following gemcitabine-based therapy; in combination with fluorouracil and leucovorin.
Opdivo® (nivolumab) 
Commercial & Medicaid or Medicare
J9299  Medical  Treatment of metastatic malignant melanoma  Covered when used for treatment of unresectable or metastatic melanoma. Requests for any condition not listed as covered require evidence of current medical literature that substantiates the drug's efficacy or that recognized oncology organizations generally accept the treatment for the condition. 
Click to get the PA form Code Benefit Use Criteria for coverage
Orencia® (abatacept)6
Commercial or Medicare
J0129 Medical

For treatment of moderate to severe symptoms of rheumatoid arthritis

Length of initial authorization: 3 months

Length of continuation authorization: 1 year

Diagnosis of moderate to severe rheumatoid arthritis

Negative TB test (provided on an annual basis)

Prior use of one or more self-injectable TNF antagonists (Enbrel, Humira) and Cimzia subcutaneous

Prior use of Remicade

Cannot be used in combination with TNF antagonists or Kineret

Ozurdex® (dexamethasone intravitreal implant) J7312 Medical Intraocular implant: 0.7 mg No prior authorization required. Covered only for the following ICD10diagnoses:

E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211-E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.3311-E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.3411-E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.3511-E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.3211- E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.3311-E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.3411-E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.3511-E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.321 –E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.3311-E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.3411-E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3511-E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.3511-E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.3211-E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.3311- E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.3411-E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.3511-E11.353 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.3111-E13.3113 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.3211-E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.3311-E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3411-E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.3511-E13.353 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
H30.001-H30.93 Chorioretinal inflammation
H34.8110 Central retinal vein occlusion, right eye, with macular edema
H34.8120  Central retinal vein occlusion, left eye, with macular edema
H34.8130  Central retinal vein occlusion, bilateral, with macular edema
H34.8310  Tributary (branch) retinal vein occlusion, right eye, with macular edema
H34.8320  Tributary (branch) retinal vein occlusion, left eye, with macular edema
H34.8330  Tributary (branch) retinal vein occlusion, bilateral, with macular edema
H35.81 Retinal edema

Perjeta® (pertuzumab)
Commercial & Medicaid
J9306 Medical Treatment of HER2-positive metastatic breast cancer

Diagnosis of HER2 positive metastatic breast cancer

Diagnosis of HER2 positive early-state breast cancer

No prior HER2 therapy for metastatic disease

Portrazza™ (necitumumab) C9475
J9999*
Medical 1 mg, chemotherapy agent Non-formulary; NOT COVERED for commercial or Medicaid plans
Prolastin® (alpha 1 proteinase inhibitor)
Commercial & Medicaid or Medicare
J0256 Medical Alpha-antitrypsin deficiency

Diagnosis of congenital alpha 1-antitrypsin deficiency

Clinically evident emphysema

FEV1 30-65% predicted

Serum AAT level < 11mM/L (< 60 mg/dL)

See PA forms for details

Prolia® (denosumab)6
Commercial & Medicaid or Medicare
J0897 Medical Treatment of postmenopausal osteoporosis

Diagnosis of nonmetastatic prostate cancer  in men receiving androgen deprivation therapy (oral bisphosphonates not required)

Diagnosis of breast cancer in women receiving aromatase inhibitors (oral bisphosphonates not required)

Diagnosis of postmenopausal osteoporosis

Documented therapeutic trial of alendronate , ibandronate, or Actonel and zoledronic acid (generic Reclast) 

Documented therapeutic trial of alendronate (step 1) and Actonel (step 2)

Coverage limited to 5 years in a lifetime combined with bisphosphonate therapy unless patient is high risk or has drug holiday with significant decline in BMD

See PA forms for details

Provenge® (sipuleucel-T)
Commercial & Medicaid or Medicare
Q2043 Medical Treatment of advanced prostate cancer

Diagnosis of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer

Eastern Cooperative Oncology Group (ECOG) performance status of 0-1

Life expectancy greater than 6 months

Serum prostate-specific antigen (PSA) ≥ 5 ng/mL

Two sequential rising PSA levels obtained 2–3 weeks apart or other evidence of disease progression

Serum testosterone < 50 ng/dL

Prior use of docetaxel every 3 weeks and steroids (NCCN category 1 recommendation)

Provenge will not be authorized for patients with any of the following:

  • Requirement for systemic corticosteroid use
  • Use of opioid analgesics for cancer-related pain
  • Visceral metastases
  • ECOG performance status ≥ 2
  • Pathologic long-bone fractures
  • Spinal cord compression
See PA forms for details
Click to get the PA form Code Benefit Use Criteria for coverage
Qtenza® (capsaicin 8% patch)6 J7335  Medical  Post-herpetic neuralgia 

Diagnosis of post-herpetic neuralgia

Prior use of all of the following:

  • Gabapentin
  • Lyrica (requires step therapy with gabapentin)
  • Generic tricyclic antidepressant (TCA)
  • oxycodone CR or morphine CR
  • Lidoderm Patch (requires prior authorization) 
Relistor® (methylnaltrexone)6
Commercial & Medicaid or Medicare
J2212 Medical Treatment of opioid-induced constipation

Diagnosis of opioid-induced constipation

Patient is receiving palliative care with advanced illness (life expectancy less than 6 months)

Patient is unresponsive with a minimum of 2 other laxative therapies or unable to tolerate oral laxatives

Patient must be free of mechanical gastrointestinal obstruction

See PA forms for details

Remicade® (infliximab)
Commercial, Medicaid or Medicare
J1745 Medical

Per 10 mg; for treatment of rheumatoid arthritis, ankylosing spondylosis, Crohn's disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis

Diagnosis of rheumatoid arthritis, ankylosing spondylosis, Crohn's disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis

Negative TB test (provided on an annual basis)

Rheumatoid arthritis requires prior use of steroids and methotrexate

Crohn's disease requires prior use of two or more conventional therapies

Ankylosing spondylitis requires BASDAI of at least 4, prior use of at least 2 NSAIDs, intra-articular steroids, and sulfasalazine in patients with peripheral arthritis

Psoriatic arthritis requires prior use of one or more DMARD

Ulcerative colitis requires prior use of conventional therapy

Plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia) and a documented trial of one topical agent, one systemic treatment, and phototherapy

The following indications require prior use of a self-injectable anti-TNF agent (e.g. Enbrel, Humira, Raptiva):

  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Plaque psoriasis
  • Crohn's disease
  • Ankylosing spondylitis
  • Ulcerative colitis
See PA forms for details
Remodulin® (treprostinil sodium)
Commercial only
J3285 Medical

Per 1 mg; for treatment of pulmonary hypertension

Length of initial authorization: 3 months

Length of continuation authorization: 1 year

Diagnosis of pulmonary arterial hypertension

Prior use of Tracleer

Prior use of Flolan

Completion of six-minute walk

Rituxan® (rituximab)5
Commercial & Medicaid or Medicare
J9310 Medical

10mg/mL

Length of initial authorization: 3 months

Length of continuation authorization

Treatment of Non-Hodgkins Lymphoma

Treatment of CD20-expressing neoplasm (e.g. chronic lymphocytic leukemia, Waldenström macroglobulinemia, hairy cell leukemia, mantle cell lymphoma)

Treatment of Thrombocytopenic purpura. One of the following is required:

  • Patient did not respond to plasma exchange;
  • Patient developed worsening disease in spite of continuing plasma exchange plus glucocorticoids;
  • Patient has relapsing disease

Treatment of Rheumatoid Arthritis requires prior use of one or more DMARDs and prior use of self-injectable anti-TNF.

See PA forms for details

Ruconest® (C1 esterase inhibitor)
Commercial & Medicaid or Medicare
J0596 Pharmacy  Treatment of hereditary angioedema

Diagnosis of hereditary angioedema

Age 12 or older

Limited to one fill of four vials. Each additional fill requires documentation of the patient's use of the previous supply of Ruconest and only the number of vials used will be replaced.

Click to get the PA form Code Benefit Use Criteria for coverage
Signifor LAR® (pasireotide)
Commercial or Medicare
J2502  Medical Treatment of acromegaly 

Must be used for treatment of acromegaly

Must have inadequate response to surgery, unless surgery is not an option

Must first try Sandostatin LAR

Simponi®, Simponi Aria® (golimumab)
Commercial & Medicaid or Medicare
J1602 Medical or Pharmacy Treatment of Ankylosing spondylitis, Psoriatic arthritis and Rheumatoid arthritis

Requires prior use of preferred agents, Enbrel and Humira (PA required for preferred agents) and Cimzi subcutaneous

Sivextro® (tedizolid)
Commercial or Medicare
J3090 Medical Treatment of acute bacterial skin and skin structure infections

Must be age 18 or older

Must fax a copy of culture and sensitivity results to Priority Health showing the patient's infection is not susceptible to alternative antibiotic treatments.

Must be started in the hospital or other health care facility and will be continued in outpatient facility for treatment of acute bacterial skin and skin structure infection (ABSSSI)

Must have documented methicillin-resistant staphylococcus aureus (MRSA)

Soliris® (golimumab)
Commercial & Medicaid or Medicare
J1300 Medical Treatment of paroxysmal nocturnal hemoglobinemia (PNH) and atypical hemolytic uremic syndrome (aHUS)

Diagnosis of either paroxysmal nocturnal hemoglobinuria (PHN) or atypical hemolytic uremic syndrome (aHUS)

Meningococcal vaccinated at least 2 weeks before treatment initiation

For patients with PNH:

  • Flow cytometric confirmation of at least 10% PHN cells
  • At least 4 or more transfusions in the last 12 months OR disabling symptoms (eg. thrombosis, and/or end organ damage)

For patients with aHUS:

  • Shiga toxin-related HUS has been ruled out
  • Patient must have received plasma exchange (PE) or plasma infusion (PI) within previous 2 weeks of starting Soliris therapy
  • Patient has a chronic need for either PE/PI or chronic dialysis
Stelara® (ustekinumab)6
Commercial & Medicaid or Medicare
J3357 Medical Treatment of moderate to severe plaque psoriasis

Moderate to severe plaque psoriasis (BSA ≥10%) who are candidates for phototherapy or systemic therapy.

Patient age ≥ 18 years

Prior use of one self-injectable biologic agent (Enbrel, Humira)

Prior use of topical, systemic and phototherapy for at least 3 months.

Psoriatic arthritis:

  • Must first try one non-biologic DMARD
  • Must first try Enbrel or Humira

Negative TB test (must be done yearly)

Patient cannot take in combination with other biologics (Enbrel, Humira, Cimzia, Simponi, Remicade, Kineret, Amevive)

Supprelin LA® (histrelin acetate)6 
Commercial & Medicaid only
J9926 Medical Implant for treatment of central precocious puberty

Documentation of a diagnosis of Central Precocious Puberty in a patient aged 2 years or older

Documented inadequate response to or intolerance to an adequate trial of Lupron injections

Click to get the PA form Code Benefit Use Criteria for coverage
Sylvant® (siltuximab)
Commercial & Medicare or Medicare
C9455 Medical Treatment of multicentric Castleman's disease (MCD) who are HIV & human herpesvirus-8 (HHV-8) negative

Diagnosis of multicentric Castleman's disease (MCD)

Must be HIV negative

Must be human herpes virus (HHV) negative

See PA forms for details

Synagis® (palvizumab)
Commercial & Medicaid only
90378 Medical

Immune globulin for respiratory syncytial virus (RSV)

Length of authorization: 5 infusions (given monthly November - March)

See PA form for coverage details
Synribo® (omacetaxine mepesuccinate)
Medicare only
J9262 Pharmacy Treatment of chronic myeloid leukemia Prior use of two or more tyrosine kinase inhibitors
Tecentriq™ (atezolizumab)
Commercial & Medicaid only
J9999
C9483
Medical Per 10mg, treatment of urothelial cancer

Diagnosis of locally advanced or metastatic urothelial carcinoma; and

  • Experienced disease progression during or following platinum-containing chemotherapy; or
  • Experienced disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy

Age 18 years or older

Eastern Cooperative Oncology Group (ECOG) performance status of 0-1

Testopel®6
Commercial & Medicaid only
J3490
S0189
Medical Treatment of hypogonadism

See PA form for complete coverage information

Click to get the PA form Code Benefit Use Criteria for coverage
Tysabri® (natalizumab)
Commercial & Medicaid or Medicare
J2323 Medical

Per 1 mg; for treatment of multiple sclerosis

Length of authorization: Indefinite

Diagnosis of relapsing-remitting form of multiple sclerosis

> 18 years of age

Prior use of Copaxone

Prior use of Rebif

Vectibix® (panitumumab)6
Commercial & Medicaid or Medicare
J9303 Medical

Treatment of advanced metastatic colorectal cancer

Length of authorization: 4 injections

Documented negative KRAS mutation status for colorectal cancer

Prior use of fluoropyridimine-containing chemo, oxaliplatin-containing chemo, or irinotecan-containing chemo

Veletri® (epoprostenol)6
Commercial & Medicaid only
J1325 Medical Treatment of primary pulmonary hypertension Diagnosis of pulmonary arterial hypertension (PAH), WHO classification I
Vimizim® (elosulfase alfa)6
Commercial only
J1322 Medical

Enzyme replacement for Morquio A Syndrome

Not covered for Medicaid

Must have Morquio A syndrome (genetic testing confirmation is required)

Must be able to walk at least 30 meters in 6 minutes

Visudyne® (verteporfin) J3396 Medical Intravenous powder for solution: 15 mg

No PA required

Covered only for the following diagnoses:

B39.4 Histoplasmosis capsulati, unspecified
B39.5 Histoplasmosis duboisii
H32 Chorioretinal disorders in diseases classified   elsewhere
H35.3210-H35.3233 Exudative age-related macular degeneration
H35.711 – H35.713 Central serous chorioretinopathy
H44.20-H44.23 Degenerative myopia

Xeomin® (incobotulinumtoxin A)1
Commercial & Medicaid or Medicare
J0588 Medical

Per unit, for various neuro-muscular uses: see prior authorization form for covered conditions

Length of authorization: 1 injection

Injections must be separated by at least 90 days

See PA forms for covered indications list

Treatment for anal fissures and headache diagnoses require prior use of conventional therapies

Click to get the PA form Code Benefit Use Criteria for coverage
Xgeva® (denosumab)6
Commercial & Medicaid only
J0897 Medical Treatment of metastatic breast and prostate cancer

Diagnosis of bone metastases

Prior use of Zometa® (not required if the patient has advanced breast or prostate cancer)

Xiaflex® (collagenase clostridium histolyticum)
Commercial & Medicaid only
J0775 Medical

Treatment of adult Dupuytren's contracture patients with a palpable cord (no PA required)

Treatment of Peyronie's disease (PA required)

Peyronie's disease:

  • Penile curvature of 30 degrees or more for 12 months or longer
  • Must first try intralesional verapamil or pentoxifylline, and
  • Erections must be painful

Note: Priority Health considers Peyronie's disease cosmetic in the absence of painful erections

Xofigo® (radium-223 dichloride)6 A9606 Medical Medical treatment of metastatic prostate cancer Covered for metastatic prostate cancer only (limited to 6 infusions). No PA required.
Xolair® (omalizumab)2
Commercial & Medicaid or Medicare
J2357 Medical

Anti-IgE therapy for treating moderate to severe allergic asthma

Length of initial authorization: 6 months

Length of continuation authorization: 1 year

Diagnosis of allergic asthma requiring daily inhaled corticosteroids

Compliant and persistent use of inhaled corticosteroids (75% adherence)

Steroid dependency > 3 months, > 2 steroid bursts in last 12 months, or > 2 ED visits in last 12 months

Positive perennial aeroallergen test

IgE level 30-700 IU/ml

> 12 years of age

No tobacco use

Yervoy® (ipilimumab)
Commercial & Medicaid or Medicare
J9228 Medical Treatment of unresectable or metastatic melanoma

Diagnosis of unresectable or metastatic melanoma

Agreement to permanently discontinue Yervoy if the patient experiences any severe adverse reactions

Prescriber must communicate directly, face-to-face, with patient to provide both verbal and printed materials regarding the safety risks associated with the use of Yervoy.

Yondelis® (trabectedin)
Commercial & Medicaid or Medicare
C9480
J9999*
Medical Treatment of soft tissue sarcomas  
Zemaira® (alpha 1 proteinase inhibitor)
Commercial & Medicaid or Medicare
J0256 Medical Alpha-antitrypsin deficiency
  • Diagnosis of congenital alpha 1-antitrypsin deficiency
  • Clinically evident emphysema
  • FEV1 30-65% predicted
  • Serum AAT level < 11mM/L (< 60 mg/dL)

See PA forms for details

Click to get the PA form Code Benefit Use Criteria for coverage
Zevalin® (ibritumomab tiuxetan)
Commercial & Medicaid only
A9543 Medical Radioimmunotherapy; indicated for the treatment of relapsed or refractory low-grade, follicular, or transformed B-cell non-Hodgkin's lymphoma (NHL)

Diagnosis of relapsed or refractory low grade, follicular, or transformed B-cell non-Hodgkin's lymphoma or rituximab refractory follicular B-cell Hodgkin's lymphoma

Platelet count > 100,000/mm3

< 25% bone marrow involvement

Neutrophil count > 1500/mm3

Cannot have had prior myeloablative therapies with autologous bone marrow transplantation or peripheral stem cell collection

Cannot have history of failed stem cell collection

Cannot have history of prior external radiation to > 25% of active marrow

Zyvox IV® (linezolid)
Commercial & Medicaid or Medicare
J2020 Medical 2mg/mL in 100, 200, and 300ml single use bags

Patient was started on Zyvox oral or IV in the hospital, or other inpatient setting and will be continuing therapy

Patient has vancomycin-resistant Enterococcus faecium infection

Patient has a documented methicillin-resistant staph aureus (MRSA) infection

See PA forms for complete details

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  1. No authorization required when Botulinum toxin is billed by neurologists, rehabilitation medicine or physical medicine.
  2. Once criteria are met, review for annual renewal of authorization. Documentation should not need to be submitted.
  3. Covered only with prescription benefit. Must be purchased through a specialty pharmacy.
  4. No authorization required when Euflexxa billed by orthopedic specialists, physiatrists, or rheumatologists.
  5. No authorization required for Rituxan for Non-Hodgkin's Lymphoma and other CD20-expressing neoplasm (e.g. chronic lymphocytic leukemia, Waldenström macroglobulinemia, hairy cell leukemia, mantle cell lymphoma).
  6. No authorization required for Medicare. Must use CPT code outlined in the CMS local coverage determination (LCD) available at http://www.cms.gov. Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

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Last modified: 11/22/2016
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