Code(s): J3396

Benefit: Medical

Notes: Intravenous Powder for Solution: 15 MG

Criteria for coverage:

• No PA for Commercial 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