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