| These services require Pre-Authorization. | Click to View Medical Policy | J-Codes |
| Actemra (Tocilizumab) |
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J3262
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| Acthar |
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J0800
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| Actimmune |
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J1830, J9216
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| Adagen |
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J2504
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| Adakveo |
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J0791
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| Adcetris |
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J9042
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| Adcirca |
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| Adempas |
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| Advate |
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J7192
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| Adynovate (Pegylated Antihemophilic Factor) |
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J7207
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| Aimovig |
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| Aldurazyme |
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J1931
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| Alecensa (Alectinib) |
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| Alferon N |
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J9215
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| Aliqopa |
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J9057
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| Alpha 1 - Antitrypsin Inhibitor Therapy |
|
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| Alphanate |
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J7186
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| AlphaNine SD |
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J7193
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| Alprostadil |
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J0270
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| Alunbrig (Brigatinib) |
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| Amitiza |
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| Ampyra |
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| Androgel 1.62% (Testosterone Gel) |
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| Antihemohilic Factor, Generic |
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J7182
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| Aralast |
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J0256
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| Asparlas |
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J9118
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| Astagraf XL |
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| Aubagio |
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| Avastin |
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J9035
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| Axiron |
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| Azelex Cream |
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| Bavencio (Avelumab) |
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| Bebulin VH |
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J7194
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| Beleodaq |
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| Benefix |
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J7195
|
| Benicar/Benicar HCT |
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| Benlysta (Belimumab) |
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J0490
|
| Bivigam |
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J1599
|
| Blincyto |
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C9449
|
| Boniva |
|
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| Botox (Inj.: Botulinum Toxin Type A, per unit) |
|
J0585
|
| Braftovi |
|
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| Carimune NF |
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J1566
|
| Caverject |
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J0270
|
| Ceredase |
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J0205
|
| Cerezyme |
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J1785
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| Chantix (Varenicline) |
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| Cialis |
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| Cimzia |
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J0718
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| Cladribine |
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J9065
|
| Coagadex (Coagulation Factor X (Human)) |
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J7175
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| Corifact |
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J7180
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| Cresemba |
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C9456
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| crysvita |
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J0584
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| Cuvitru (Immune Globulin) |
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| Cyramza |
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C9025
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| Cystagon (Cysteamine) |
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| Cytogam (Cytomegalovirus Immune Globulin (CMV-IGIV)) |
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J0850
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| Darzalex (Daratumumab) |
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J9145
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| Daytrana |
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J0718
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| Dextenza |
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C9048
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| Diclofenac Gel 3% |
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| Differin Cream/Gel |
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| Diovan/Diovan HCT (Valsartan & Valsarta/HCTZ) |
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| Dysport |
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J0586
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| Edarbi/Edarbyclor (Azilsartan & Azilsatan/Chlorthalidone) |
|
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| Edex |
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J0270
|
| Elaprase |
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J1743
|
| Elelyso |
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J3060
|
| Elzonris |
|
C9049
|
| Emcyt (Estramustine) |
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| Emgality |
|
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| Empliciti (Elotuzumab) |
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J9176
|
| Enablex (Darifenacin) |
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| Enhertu |
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J9358
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| Entyvio |
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J3380
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| Epclusa (Sofosbuvir/Velpatasvir) |
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| Erbitux |
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J9055
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| Erwinaze |
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J9019
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| Esbriet (Pirfenidone) |
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| Eylea |
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J0178
|
| Fabrazyme |
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J0180
|
| Factor Products for Bleeding Disorders |
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| Farxiga |
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| Farydak |
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| Fentora |
|
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| Firazyr (Icatibant) |
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J1744
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| Flebogamma |
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J1567
|
| Flolan |
|
J1325
|
| Flolan Diluent |
|
S0155
|
| Gammagard |
|
J1566
|
| Gammaked |
|
J1561
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| Gammaplex |
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J1557
|
| Gammaplex NOS |
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J1599
|
| Gamunex |
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J1561
|
| Gazyva |
|
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| Genotropin |
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J2941
|
| Gesterone |
|
J2675
|
| Gestrin |
|
J2675
|
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