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January 01, 2023

Provider administered drugs prior authorization updates

UnitedHealthcare Community Plan of Pennsylvania

Effective for dates of service starting Feb. 1, 2023, we will require prior authorization for the following medications and CPT® codes:

Drug HCPCS Drug HCPCS
Advate®, Kogenate® FS, Recombinate J7192 Idelvion® J7202
Adynovate® J7207 Jivi® J7208
Afstyla® J7210 Koate®, Hemofil® M J7190
Alphanate® J7186 Kovaltry® J7211
AlphaNine® SD, Mononine® J7193 Lucentis® J2778
Alprolix® J7201 Miacalcin® (calcitonin) J0630
Aranesp® J0881 Mircera® J0888
Arcalyst® J2793 Novoeight® J7182
Aveed® J3145 NovoSeven® RT J7189
Benefix®, Ixinity® J7195 Nuwiq® J7209
Beovu® J0179 Obizur® J7188
Boniva® (ibandronate) J1740 Phenergan® (promethazine) J2550
Byooviz® Q5124 Profilnine® J7194
Chlorpromazine® J3230 Rebinyn® J7203
Coagadex® J7175 Reclast®, Zoledronic Acid J3489
Corifact® J7180 Retacrit® Q5106
Depo-Testosterone (testosterone cypionate) J1071 Rixubis® J7200
Durolane® J7318 RiaSTAP® J7178
Eloctate® J7205 SevenFACT® J7212
Epogen®, Procrit® J0885 Susvimo® J2779
Esperoct® J7204 Testopel® S0189
Euflexxa® J7323 Testosterone Enanthate J3121
Eylea® J0178 Tigan® J3250
Feiba® NF J7198 Tretten® J7181
Fibryga® J7177 Vabysmo® J2777
Fluphenazine® Decanoate J2680 Visudyne® J3396
Gelsyn-3® J7328 Vonvendi® J7179
Geodon® (ziprasidone mesylate) J3486 Wilate® J7183
Haloperidol® Decanoate J1631 Xyntha® J7185
Hemlibra® J7170 Zinplava® J0565
Hemophilia clotting factor, not otherwise classified J7199 Zyprexa® (olanzapine) S0166
Humate-P® J7187

Determination and review timeline

We will complete prior authorization reviews according to state-defined requirements. Notifications of the case determination, including appeal rights when applicable, will be provided within the required time frame.

We’ll issue a denial decision if we don’t receive sufficient clinical information to complete the review. To prevent denials due to a lack of information, include all required clinical information when you submit the prior authorization request.

Please submit prior authorization requests according to the plan protocols.

How to submit prior authorization

Questions?

For questions related to these prior authorization requirements, call the Provider Services number on the member’s health care ID card.

CPT® is a registered trademark of the American Medical Association.
PCA-1-22-04295-C&S-News_12122022
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