No prior authorization required for:

• Emergency room
• Inpatient
• Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J3490, S0189

Benefit: Medical

Notes: Treatment of hypogonadism

Criteria for coverage:

• See PA form for criteria for Commercial

• Not Covered for Medicare