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.
  • Drugs in boldface must be ordered through a specialty pharmacy.
    Go to the specialty pharmacy fax order form (739KB PDF).
  • Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
Injectable drugs requiring prior authorization all plans
Updated January 2016
Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Actemra (tocolizumab)6 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)

Acthar, Medicare

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) 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) J1260 Medical Per 10 mg; antiemetic; PA required ONLY for home infusion providers
Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Aralast (alpha 1 proteinase inhibitor - human) 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) J9032 Medical Treatment of refractory CLL

Diagnosis of CLL

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

Aveed (testosterone undeconoate) 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 (belinostat), commercial and Medicaid PA form

Beleodaq Medicare PA form

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) 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

Blincyto, 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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Boniva (ibandronate sodium) 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

Botox (Botulinum toxin type A)1 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 form for a list of covered indications

See PA form for Medicare

Cimzia (certolizumab) 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)

Cyramza (ramucirumab) J9308
Medical Treatment of gastric cancer

Treatment of advanced gastric cancer, or

Gastro-esophageal junction adenocarcinoma

Dalvance (dalbavancin) 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  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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Dysport (botulinumtoxin A)1 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 a list of covered indications

See PA form for Medicare

Enbrel (etanercept)3 (etanercept) 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) 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) 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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Erwinaze (asparaginase erwinia chrysanthemi) 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 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
Fabrazyme (agalsidase beta) 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 J1325 Medical Treatment of primary pulmonary hypertension Diagnosis of pulmonary arterial hypertension (PAH), WHO classification I
Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Forteo (teriparatide)2,3 (teriparatide) 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) J3490
C9399
Pharmacy Treatment of short bowel syndrome

See PA form for Medicare

Gazyva (obinutuzumab) 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) 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:

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 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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage

Hyaluronic acids4,6

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

J7321 Medical

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 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.
Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Increlex 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 J1561 Medical Gamunex See PA form for covered indications
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 the drug name
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 379.27 vitreomacular adhesion

Jevtana (carbazitaxel) 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 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 form for Medicare

Keytruda (pembrolizumab)6 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 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) 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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Kynamro (mipomersen sod)3 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 J0202  Medical  Treatment of multiple sclerosis   
Lucentis (ranibizumab)6 J2778 Medical Treatment of AMD and RVO Prior use of Avastin (bevacizumab)
Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Macugen (pegaptinib)6 J2503 Medical Treatment of AMD Prior use of Avastin (bevacizumab)
Makena (hydroxyprogesterone caproate)6 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 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 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 form for a list of covered indications

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

See PA form for Medicare
Nplate (romiplostim) 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

Nulojix (belatacept)6 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

Opdivo (nivolumab)  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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Orencia (abatacept)6 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 diagnoses:

362.30 Retinal vascular occlusion, unspecified

362.35-362.37 Retinal vascular occlusion

362.83 Retinal edema

363.00-363.08 Focal choroiditis

363.10-363.15 Disseminated choroiditis

363.20-363.22 Choroiretinitis, par planitis

Perjeta (pertuzumab) 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

Prolastin (alpha 1 proteinase inhibitor) 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 form for Medicare

Prolia (denosumab)6 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 form)

See PA form for Medicare

Provenge
(sipuleucel-T)
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 form for Medicare
Click the drug name
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 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 form for Medicare

Remicade (infliximab) 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 form for Medicare
Remodulin (treprostinil sodium) 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 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 form for Medicare

Ruconest (C1 esterase inhibitor)  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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Signifor LAR (pasireotide)  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) (golimumab) 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) 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) 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 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 
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 the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Sylvant (siltuximab) 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 form for Medicare

Synagis (palvizumab) 90378 Medical

Immune globulin for respiratory syncytial virus (RSV)

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

See PA form for complete details coverage information
Synribo (omacetaxine mepesuccinate) J9262 Pharmacy Treatment of chronic myeloid leukemia Prior use of two or more tyrosine kinase inhibitors
Testopel6 J3490
S0189
Medical Treatment of hypogonadism

See PA form for complete coverage information

See PA form for Medicare

Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Tysabri (natalizumab) 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 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 J1325 Medical Treatment of primary pulmonary hypertension Diagnosis of pulmonary arterial hypertension (PAH), WHO classification I
Vimizim (elosulfase alfa)6 J1439 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:

  • 115.02 Histoplasma capsulatum retinitis
  • 115.12 Histoplasma duboisii retinitis
  • 115.92 Unspecified Histoplasmosis retinitis
  • 360.21 Progressive high (degenerative) myopia
  • 362.16 Retinal neovascularization NOS
  • 362.52 Exudative senile macular degeneration

Note: Diagnosis 362.16 must be secondary to either 115.02 or 360.21 for coverage to occur

Xeomin (incobotulinumtoxin A)1 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 form for a list of covered indications

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

See PA form for Medicare

Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Xgeva (denosumab)6 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) 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 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) 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.

Zemaira (alpha 1 proteinase inhibitor) 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 form for Medicare

Click the drug name
to get the PA form
Code Benefit Use Criteria for coverage
Zevalin (ibritumomab tiuxetan) 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 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 form 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: 5/20/2016
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