***Coverage Of Gene Therapies Is Not Addressed In This .

GHC SPECIALTY MEDICATIONSLast Update: 10/1/2021***Coverage of gene therapies is not addressed in this document***NEW TO MARKET MEDICATIONSNewly-available medications may be subject to GHC-SCW’s Coverage of New-to-market Drugs policy. If the medicationyou are seeking coverage for is listed below, it is not covered and claims for the drug will be denied in concordance withthe policy. The list is current as of the date of this document. Drugs which have been made available since the date ofthis document will not be covered.HCPCS CodeJ3590J9999J3590J3590J3490J3590J9999Brand ivdakGeneric Nameaducanumabasparaginase erwinia chrysanthemi-rywnanifrolumab-fniaavalglucosidase alfa-ngptdifelikefalinranibizumab-nunatisotumab vedotin-tftvPHARMACY BENEFIT ONLY MEDICATIONSCoverage of the following medications is restricted to the Pharmacy benefit. Claims submitted on the Medical benefitwill be denied. Please note that these drugs may require Prior Authorization per the Formulary.HCPCS 3490J7639J3590J3357J0593J7682J7686Brand mptaOral prescription drug non chemoOral prescription drug non vasoGeneric NameCertolizumab pegolEtanerceptsatralizumabC1 Esterase InhibitorEmicizumab-kxwhAdalimumabofatumumabOral prescription drug non chemoOral prescription drug non chemoLetermovirDornase cin Inh SolnTreprostinil Inh Soln

GHC SPECIALTY MEDICATIONSLast Update: 10/1/2021SPECIALTY INJECTABLES PRIOR AUTHORIZATION LISTPrior authorization is required for clinic-administered injectable medications. Monthly updates will be added to the PriorAuthorization list. Providers are reminded to review the Prior Authorization list on a regular basis for any updates orchanges which may be added.PLEASE NOTE: Magellan or GHC Prior Authorization?The medications highlighted below in yellow required Prior Authorization from our partner, Magellan. Please click HEREto start the Prior Authorization process for these medications.All other medications on the list below require Prior Authorization from GHC-SCW. Please click HERE to start the PriorAuthorization process for these medications. Please contact Member Services with specific code information todetermine if an item or service requires prior authorization. Member Services Phone: (800) 605-4327.MAGELLAN RX SPECIALTY PHARMACY: When (and only when) GHC is the primary payor, select drugs must besourced through Magellan Rx Specialty Pharmacy. Users will be guided in the Magellan Rx PA portal to set this up. Pleasebe aware that if your practice is accustomed to “buy-and-bill,” those claims for reimbursement will be denied.HCPCSBrand NameGeneric J0800Acthar HPCorticotropinJ2504AdagenPegademase rentuximab opaAloxiAmondys tAranespAlpha-1 proteinase sparlasOfatumumabIVIG (Human)-slraCalaspargase pegol-mknlJ9035AvastinBevacizumab Only for Cancer DxAldurazymeMandatoryDistributionthroughMagellan RxSpecialtyPharmacyYYYYYY

GHC SPECIALTY MEDICATIONSHCPCSLast Update: 10/1/2021Brand NameGeneric NameQ5121AvsolaInfliximab axxqA9590AzedraIobenguane J0597BeovuBerinertBrolucizumab-dbllC1 InhibitorJ9229BesponsaInotuxumab ozogamicinJ1556J9037BivigamBlenrepIntravenous Immune onase alfaJ9999J1566CamceviCarimune NFleuprolide mesylateIntravenous Immune zumabJ0598J1448CinryzeCoselaC1 InhibitorTrilaciclibJ3590CutaquigImmune globulin SC (human)-hippJ1555CuvitruSubcutaneous Immune ratumumabJ9144Darzalex FasproDefitelioDaratumumab and luronan or sTaliglucerase alfaLeuprolide acetate (for iEnhertuElotuzumabFam-trastuzumab n RxSpecialtyPharmacyYYYYYYY

GHC SPECIALTY MEDICATIONSHCPCSLast Update: 10/1/2021Brand NameGeneric aluronan or derivativeEvinacumab-dgnbJ1428J3111Exondys e heme (non-esrd)Leuprolide AcetateferumoxytolQ0139Feraheme 5J1572FlebogammaDegarelixIntravenous Immune GlobulinMandatoryDistributionthroughMagellan dbLevoleucovorin CalciumEmapalumab-lzsgJ1569Gammagard LiquidIntravenous Immune GlobulinYJ1566J1561Gammagard S/DGammakedImmune GlobulinIntravenous Immune GlobulinYJ1557GammaplexIntravenous Immune GlobulinJ1561Gamunex-CIntravenous Immune GlobulinYYJ0132J9301Ganirelix luronan or derivativeYJ7328Gelsyn-3Hyaluronan or derivativeJ7320Genvisc 850GivlaariHyaluronan or derivativeJ0223J0257J9179YHalavenGivosiranAralast, Aralast NPEribulinJ9355J9356HerceptinHerceptin HylectaTrastuzumabTrastuzumab and assiaY

GHC SPECIALTY MEDICATIONSHCPCSLast Update: 10/1/2021Brand NameGeneric NameJ1559HizentraSubcutaneous Immune GlobulinJ7321HyalganHyaluronan or derivativeJ7322J1575HymovisHyQviaHyaluronan or derivativeSubcutaneous Immune crelexTalimogene ybJ9198J1439InfugemInjectaferIntravenous ImmuneGlobulinIprivaskGemcitabineFerric 319J9207J9281MandatoryDistributionthroughMagellan RxSpecialtyPharmacyYYIntravenous Immune GlobulinDesirudinJelmytoIxabepiloneMitomycin for pyelocaliceal 4JevtanaKadcylaCabazitaxelAdo-trastuzumab tuzumab-annsJ2840J0642KanumaKhapzorySebelipase eLumoxitiRanibizumabJ9217Lupron DepotJ1950Lupron DepotYYAlglucosidase alfaMoxetumomab pasudotox-tdfkLeuprolide acetate (for depotsuspension)Leuprolide acetate (for depotsuspension)YY

GHC SPECIALTY MEDICATIONSHCPCSLast Update: 10/1/2021Brand NameGeneric NameLeuprolide acetate (for depotsuspension)lutetium Lu 177 dotatateMandatoryDistributionthroughMagellan RxSpecialtyPharmacyYJ1950Lupron Depot qiboVincristine LiposomalJ3397MepseviiVestronidase alfa-vjvkJ2788J9349MicrhogamMonjuviRho(D) immune globulinTafasitamab-cxixJ1437Monoferricferric derisomaltoseJ7327MonoviscHyaluronan or derivativeJ9203J0587MylotargMyoblocGemtuzumuab amOctreotide AcetateOgivriIntravenous Immune Irinotecan yaluronan or derivativeLumasiranJ9177PadcevEnfortumab vedotin-ejfvJ1599J9304PanzygaPemfexyIntravenous Immune Y

GHC SPECIALTY MEDICATIONSHCPCSLast Update: 10/1/2021Brand NameGeneric NameJ9247Pepaxtomelphalan zumabPertuzumab, trastuzumab andhyaluronidasePolatuzumab zumabJ1459MandatoryDistributionthroughMagellan RxSpecialtyPharmacyYPrivigenZiconotideIntravenous Immune GlobulinYJ0885Procrit/EpogenEpoetin ase xan HycelaRituximab and hyaluronidase lyophilizedC1 Esterase Inhibitor azimamivantamab-vmjwPlasminogen, human-tmvhJ2353Sandostatin esseAfamelanotideJ1602J3490Simponi ARIASodium HyaluronateGolimumab1% hyaluronan or ximan-arrxYYYY

GHC SPECIALTY MEDICATIONSHCPCSLast Update: 10/1/2021Brand NameGeneric NameMandatoryDistributionthroughMagellan omer-Sodium lara IVUstekinumabJ7321J9226SupartzSupprelin LAHyaluronan or derivativeHistrelin Implant (50 mg)J1627SustolGranisetron ynriboSynviscOmacetaxineHyaluronan or derivativeYJ7325Synvisc-OneHyaluronan or derivativeYJ7331SynojoyntHyaluronan or delvyTriptorelinHyaluronan or derivativeSacituzumab ibixHistrelin 321Visco-3YYTriptorelin PamoateHyaluronan or derivativeElosulfase AlfaHyaluronan or derivativeYYY

GHC SPECIALTY MEDICATIONSHCPCSLast Update: 10/1/2021Brand NameGeneric eJ3032J1429VyeptiVyondys nDaunorubicin and cytarabineImmune globulin SC nADenosumabJ0775XiaflexJ2357XolairCollagenase Clostridium imumabTrabectedinJ7314YutiqFluocinolone iraZepzelcaAlpha1-Proteinase Inhibitor C9084Zynlontaloncastuximab tesirine-lpylMandatoryDistributionthroughMagellan RxSpecialtyPharmacyYYYYY

Sep 01, 2021 · J9155 Firmagon Degarelix J1572 Flebogamma Intravenous Immune Globulin Y J9307 Folotyn Pralatrexate Q5108 Fulphila Pegfilgrastim-jmdb . J1950 Lupron Depot Leuprolide acetate (for depot suspension) Y J1950 Lupron Depot Ped Leuprolide acetate (for depot suspension) Y A9513 Lutathera lutetium Lu 177 dotatate