Code - University Of Utah

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Below is the list of Medical Drug J-codes that require pre-service review for Commercial and Individual Plans. Please submit requests using the Medical Prior Auth Medical Electronic Request Form (select Medical Pharmacy from the drop down) or the PDF form that are available under Prior Authorization Forms, attach all necessary clinical documentation and submit to the Pharmacy Team by either fax to 801-213-1547 or by email: uhealthplanspharmacyteam@hsc.utah.edu If you have questions or need assistance regarding medical pharmacy please call for Individual & Family Plans: 833-981-0214, Commercial Groups: 833-981-0213. For questions regarding retail pharmacy please call RealRx pharmacy customer service: Individual & Family Plans: 855-869-4769, Commercial Groups: 855-509-8142. Codes with a * in the PA Status require prior authorization for Carson Tahoe members. Procedure Code 11980 90378 90626 90627 90671 90677 90758 99601 99602 0537T 0538T 0539T 0540T A4238 A9276 Description PA Status IMPLANT,HORMONE,SUBCUTANEOUS RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG EA TICK-BORNE ENCEPHALITIS VIRUS VACCINE, INACTIVATED; 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE TICK-BORNE ENCEPHALITIS VIRUS VACCINE, INACTIVATED; 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE PNEUMOCOCCAL CONJUGATE VACCINE, 15 VALENT (PCV15), FOR INTRAMUSCUALR USE PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCUALR USE ZAIRE EBOLAVIRUS VACCINE, LIVE, FOR INTRAMUSCUALR USE HOME INFUSION/VISIT, 2 HRS HOME INFUSION, EACH ADDTL HR CAR-T THERAPY HRVG BLD DRV T LMPHCYT PR DAY CAR-T THERAPY PREP BLOOD DERIVED T LMPHCYT FOR TRANSPORTATION CAR-T THERAPY RECEIPT & PREP CAR-T CELLS FOR ADMIN CAR-T THERAPY AUTOLOGOUS CELL ADMINISTRATION SUPPLY ALLOW FOR ADJUNCTIVE CONT GLUCOSE MONITOR (CGM) 1 MONTH SUPPLY Auth Required Auth Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required. Quantity Limit applies: Medtronic quantity of 15 allowed in 105 day rolling period. Dexcom covered under retail pharmacy benefit. Please contact Pharmacy Customer Service for assistance. DISPOSABLE SENSOR, CGM SYS 1 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

A9277 EXTERNAL TRANSMITTER, CGM A9278 EXTERNAL RECEIVER, CGM SYS A9513 A9590 A9606 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4187 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 LUTETIUM LU 177, DOTATATE, THERAPEUTIC, 1 MILLICURIE IODINE I-131, IOBENGUANE, 1 MILLICURIE RADIUM RA-223 DICHLORIDE, THERAPEUTIC, PER MICROCURIE PARENTERAL 50% DEXTROSE SOLU PARENTERAL SOL AMINO ACID 3. PARENTERAL SOL AMINO ACID 5. PARENTERAL SOL AMINO ACID 7PARENTERAL SOL AMINO ACID PARENTERAL SOL CARB 50% PARENTERAL SOL 10 GM LIPIDS OMEGAVEN, 10 GRAMS LIPIDS PARENTERAL SOL AMINO ACID & PARENTERAL SOL 52-73 GM PROT PARENTERAL SOL 74-100 GM PRO PARENTERAL SOL 100GM PROTE PARENTERAL NUTRITION ADDITIV PARENTERAL SUPPLY KIT PREMIX PARENTERAL SUPPLY KIT HOMEMI PARENTERAL ADMINISTRATION KI PARENTERAL SOL RENAL-AMIROSY PARENTERAL SOL HEPATIC-FREAM Auth Required. Quantity Limt applies: Medtronic quantity of 4 allowed in a 365 day rolling period. Dexcom covered under retail pharmacy benefit. Please contact Pharmacy Customer Service for assistance. Auth Required. Quantity limit applies: Medtronic quantity of 1 allowed in a 365 day rolling period. Dexcom covered under retail pharmacy benefit. Please contact Pharmacy Customer Service for assistance. Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Not Required Auth Required Auth Required Auth Required Auth Required Auth Required 2 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

B5200 B9004 B9006 B9999 C8957 C9046 C9047 C9088 C9089 C9101 C9113 C9143 C9144 C9248 C9254 C9257 C9285 C9290 C9293 PARENTERAL SOL STRES-BRNCH C PARENTERAL INFUS PUMP PORTAB PARENTERAL INFUS PUMP STATIO PARENTERAL SUPP NOT OTHRWS C PROLONGED IV INF, REQ PUMP COCAINE HCL NASAL SOLUTION FOR TOPICAL ADMIN, 1 MG INJ, CAPLACIZUMAB-YHDP, 1 MG INSTILLATION, BUPIVACAINE AND MELOXICAM, 1 MG/0.03 MG BUPIVACAINE, COLLAGEN-MATRIX IMPLANT, 1 MG INJECTION, OLICERIDINE, 0.1 MG INJ PANTOPRAZOLE SODIUM, VIA COCAINE HCL NASAL SOLUTION (NUMBRINO), 1 MG INJ, BUPIVACAINE (POSIMIR), 1 MG INJ, CLEVIDIPINE BUTYRATE INJECTION, LACOSAMIDE 1MG BEVACIZUMAB INJECTION 0.25MG LIDOCAINE 70 MG/TETRACAINE 70 MG, PER PATCH INJECTION BUPIVACAINE LIPOSOME 1 MG INJ, GLUCARPIDASE, 10 UNITS C9399 UNCLASSIFIED DRUGS OR BIOLOG C9460 C9462 C9482 C9488 E0779 E0780 E0781 E0791 E2102 E2103 G0088 INJ, CANGRELOR, 1 MG INJ, DELAFLOXACIN, 1 MG INJ, SOTALOL HYDROCHLORIDE, 1 MG INJ, CONIVAPTAN HYDROCHLORIDE, 1 MG AMB INFUSION PUMP MECHANICAL MECH AMB INFUSION PUMP 8HRS EXTERNAL AMBULATORY INFUS PU PARENTERAL INFUSION PUMP STA ADJUNCTIVE CONT GLUCOSE MONITOR OR RECEIVER NON-ADJUNCTIVE, NON-IMPLANTED CONT GLUCOSE MONITOR OR RECEIVER PROF SVCS, INITIAL HOME VISIT, ADMIN NON-CHEMO IV INFUSION, EA DRUG ADMIN, PER DAY, EA 15 MIN PROF SVCS, INITIAL HOME VISIT, ADMIN SUBCUTANEOUS IMMUNOTHERAPY OR OTHER INFUSION DRUG/BIOLOGIC, EA DRUG ADMIN, PER DAY, EA 15 MIN G0089 Auth Required Auth Required Auth Required Auth Required Auth Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Required Auth Required when billing over 500 Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required 3 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J0120 J0121 J0122 PROF SVCS, INITIAL HOME VISIT, ADMIN IV CHEMO/HIGHLY COMPLEX INFUSION DRUG/BIOLOGIC, EA INFUSION DRUG ADMIN, PER DAY, EA 15 MIN TETRACYCLINE UP TO 250MG INJ INJ, OMADACYCLINE, 1 MG INJ, ERAVACYCLINE, 1 MG J0129 ABATACEPT INJ,10MG J0130 J0131 J0132 J0133 J0134 ABCIXMAB 10MG INJECTION INJ, ACETAMINOPHEN, 10 MG ACETYLCYSTEINE INJECTION ACYCLOVIR INJECTION INJECTION, ACETAMINOPHEN (FRESENIUS KABI), 10 MG J0135 ADALIMUMAB INJECTION J0136 J0153 J0171 J0172 J0173 J0178 J0179 J0180 J0185 J0190 J0200 J0202 J0205 J0207 J0210 INJECTION, ACETAMINOPHEN (B BRAUN), 10 MG INJ, ADENOSINE, 1 MG ADRENALIN EPINEPHRINE 0.1 MG INJ INJ, ADUCANUMAB-AVWA, 2 MG INJECTION, EPINEPHRINE (BELCHER) NOT THERAPEUTICALLY EQUIVALENT TO J0171, 0.1 MG INJ, AFLIBERCEPT, 1 MG INJ, BROLUCIZUMAB-DBLL, 1 MG AGALSIDASE BETA INJECTION INJ, APREPITANT, 1 MG BIPERIDEN LACTATE PER 5MG INJ ALATROFLOXACIN MESYL 100MG INJ INJ, AALEMTUZUMAB, 1 MG ALGLUCERASE PER 10 UNITS INJ AMIFOSTINE 500 MG METHYL HCI UP TO 250MG INJ G0090 Auth Required Auth Not Required Not Covered Auth Required Auth Required. Subcutaneous therapy goes through retail pharmacy benefit. Please contact pharmacy customer service for retail pharmacy benefit. Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Not Required Auth Not Required Auth Not Required Not Covered* Auth Not Required Auth Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Not Required Auth Not Required 4 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J0219 J0220 J0221 J0222 J0223 J0224 J0225 J0248 INJECTION, AVALGLUCOSIDASE ALFA-NGPT, 4 MG ALGUCOSIDASE ALFA 10MG INJ INJ, ALGLUCOSIDASE ALFA, (LUMIZYME), 10 MG INJ, PATISIRAN, 0.1 MG INJECTION, GIVOSIRAN, 0.5 MG INJECTION, LUMASIRAN, 0.5 MG INJECTION, VUTRISIRAN, 1 MG INJ, REMDESIVIR, 1MG J0256 ALPHA 1 PROTEINASE INH 10MG J0257 INJ, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 MG J0270 J0275 J0278 J0280 J0282 J0283 J0285 J0287 J0288 J0289 J0290 J0291 J0295 J0300 J0330 J0348 J0350 J0360 ALPROSTADIL PER 1.25MCG INJ ALPROSTADIL URETHRAL SUPPOSIT RY AMIKACIN SULFATE INJECTION AMINOPHYLLIN TO 250MG INJ AMIODARONE HCL 30 MG INJ INJECTION, AMIODARONE HYDROCHLORIDE (NEXTERONE), 30 MG AMPHOTER B ANY LIPID 50MG INJ AMPHOTERICIN B LIPID COMPLEX 10MG AMPHOTERCIN B CHOL SULF 10MG AMPHOTERICIN B LIPOSOME 10MG AMPICILLIN 500 MG INJ INJ, PLAZOMICIN, 5 MG AMPICILLIN SODIUM PER 1.5 GM AMOBARBITAL TO 125 MG INJ SUCCINYCHOLINE CHL TO 20MG INJ ANIDULAFUNGIN INJ, 1MG ANISTREPLASE PER 30 UNITS INJ HYDRALAZINE HCL UP TO 20MG INJ Not Covered Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required 5 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J0364 APOMORPHINE HYDROCHL INJ, 1MG J0365 J0380 J0390 J0395 J0400 J0401 J0456 J0461 J0470 J0475 J0476 J0480 J0485 J0490 J0491 J0500 J0515 J0517 J0520 J0558 J0561 J0565 J0567 J0570 J0571 J0572 J0573 J0574 J0575 J0583 APROTONIN, 10,000 KIU METARAMINOL BITAR PER 10MG CHLOROQUINE HCL TO 250MG INJ ARBUTAMINE HCL 1MG INJ ARIPIPRAZOLE INJ 0.25MG INJECTION ARIPIPRAZOLE EXTENDED RELEASE 1 MG AZITHROMYCIN 500MG INJ ATROPINE SULFATE INJ 0.01MG DIMERCAPROL 100MG INJ BACLOFEN 10 MG INJECTION BACLOFEN 50MCG INJ BASILIXIMAB INJ, BELATACEPT, 1 MG INJ, BELIMUMAB, 10 MG INJECTION, ANIFROLUMAB-FNIA, 1 MG DICYCLOMINE HCL UP TO 20MG BENZTROPINE MESYLATE 1MG INJ INJ, BENRALIZUMAB, 1 MG BETHANECHOL CH MYT URE 5MG INJ PENG BENZATHINE/PROCAINE 100,000 U INJ PENICILLIN G BENZATHINE 100,000 U INJ INJ, BEZLOTOXUMAB, 10 MG INJECTION, CERLIPONASE ALFA 1 MG BUPRENORPHINE IMPLANT, 74.2 MG BUPRENORPHINE, ORAL, 1 MG BUPRENORPHINE/NALOXONE, ORAL, LESS THAN OR EQUAL TO 3 MG BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 3 MG, BUT LESS THAN OR EQUAL TO 6 MG BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 10 MG BIVALIRUDIN Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Not Covered Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required 6 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J0584 INJECTION, BUROSUMAB-TWZA 1M J0585 BOTULINUM TOXIN A PER UNIT J0586 ABOBOTULINUMTOXINA 5 UNITS J0587 BOTULINUM TOXIN TYPE B/100 UNI J0588 INJ, INCOBOTULINUMTOXIN A, 1 UNIT J0591 INJECTION, DEOXYCHOLIC ACID, 1 MG J0592 BUPRENOPHRINE HCL 0.1MG INJ J0593 J0594 J0595 J0596 J0597 J0598 INJ, LANADELUMAB-FLYO, 1 MG BUSULFAN INJ, 1MG BUTORPHANOL TARTRATE, 1MG INJ, C1 ESTERASE INHIBITOR (RECOMBINANT), RUCONEST, 10 UNITS C-1 ESTERASE, BERINERT 10 UNITS INJ C1 ESTERASE INHIBITOR INJ 10 UNITS J0599 INJECTION, HAEGARDA 10 UNITS Auth Required Auth Not Required. Not Covered for DX: L11.8, L57.2, L57.4, L66.4, L87.1, L90.3, L90.4, L92.2, L94.8, L98.5, L98.6 Auth Not Required. Not Covered for DX: L11.8, L57.2, L57.4, L66.4, L87.1, L90.3, L90.4, L92.2, L94.8, L98.5, L98.6 Auth Not Required. Not Covered for DX: L11.8, L57.2, L57.4, L66.4, L87.1, L90.3, L90.4, L92.2, L94.8, L98.5, L98.6 Auth Not Required. Not Covered for DX: L11.8, L57.2, L57.4, L66.4, L87.1, L90.3, L90.4, L92.2, L94.8, L98.5, L98.6 Plan Exclusion not covered for cosmetic use. Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. 7 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J0600 J0604 J0606 J0610 J0611 J0620 EDETATE CALCIUM DISODIUM INJ CINACALCET, ORAL, 1 MG, (FOR ESRD ON DIALYSIS) INJ, ETELCALCETIDE, 0.1 MG CALCIUM GLUCONATE PER 10ML INJ INJECTION, CALCIUM GLUCONATE (WG CRITICAL CARE), PER 10 ML CALCIUM GLYCER LACT 10 ML INJ J0630 CALCITONIN SALMON 400 UNIT INJ J0636 J0637 J0638 J0640 J0641 J0642 J0670 J0689 J0690 J0691 J0692 J0694 J0695 J0696 J0697 J0698 J0699 J0701 J0702 J0703 J0706 J0710 J0712 J0713 CALCITRIOL INJ 0.1 MG CASPOFUNGIN ACETATE 5MG INJ CANAKINUMAB 1 MG INJECTION LEUCOVORIN CALCIUM 50MG INJ LEVOLEUCOVORIN CAL 0.5MG INJ INJ, LEVOLEUCOVORIN (KHAPZORY), 0.5 MG MEPIVACAINE HCL 10ML INJ INJECTION, CEFAZOLIN SODIUM (BAXTER), 500 MG CEFAZOLIN SODIUM 500MG INJ INJECTION, LEFAMULIN, 1 MG CEFEPIME HYDROCHLORIDE INJ 500MG CEFOXITIN SODIUM 1GM INJ INJ, CEFTOLOZANE 50 MG AND TAZOBACTAM 25 MG CEFTRIAXONE SODIUM 250MG INJ STERILE CEFUROXIME 750MG INJ CEFOTAXIME SODIUM PER G INJ, CEFIDEROCOL, 10 MG INJECTION, CEFAZOLIN SODIUM (BAXTER), 500 MG BETAMETH ACET 3MG W SOD PHOS 3MG INJECTION, CEFEPIME HYDROCHLORIDE (B BRAUN), 500 MG CAFFEINE CITRATE INJ 5 MG CEPHAPIRIN SODIUM 1GM INJ INJ, CEFTAROLINE FOSAMIL, 10 MG CEFTAZIDIME PER 500MG INJ Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Not Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Not Required 8 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J0714 J0715 J0716 INJ, CEFTAZIDIME AND AVIBACTAM, 0.5 G/0.125 G CEFTIZOXIME SODIUM 500 MG INJ INJ, CENTRUROIDES IMMUNE F(AB)2, UP TO 120 MILLIGRAMS J0717 INJECTION CERTOLIZUMAB PEGOL 1 MG J0720 CHLORAMPHENICOL SOD SUC 1G INJ J0725 CHOR GONADOTROPIN 1000U INJ J0735 J0739 J0740 J0741 J0742 J0743 J0744 J0745 J0770 J0775 J0780 J0791 J0795 J0800 J0834 J0840 J0841 J0850 J0875 J0877 J0878 J0879 CLONIDINE HCL 1 MG INJ INJECTION, CABOTEGRAVIR, 1 MG CIDOFOVIR 375MG INJECTION INJ, CABOTEGRAVIR AND RILPIVIRINE, 2MG/3MG INJECTION, IMIPENEM 4 MG, CILASTATIN 4 MG AND RELEBACTAM 2 MG CILASTATIN SOD IMIP 250MG INJ CIPROFLOXACIN IV INF,200MG CODEINE PHOSPHATE 30 MG INJ COLISTIMETHATE SOD 150MG INJ COLLAGENASE, CLOST HIST 0.01 MG INJ PROCHLORPERAZINE TO 10MG INJ INJECTION, CRIZANLIZUMAB-TMCA, 5 MG CORTICORELIN OVINE TRIFLUTAL CORTICOTROPIN UP TO 40 UN INJ COSYNTROPIN CORTROSYN INJ 0.25MG INJ, CROTALIDAE POLYVALENT IMMUNE FAB (OVINE), UP TO 1 GRAM INJ, CROTALIDAE IMMUNE F(AB)2 (EQUINE), 120 MG CYTOMEGALOVIRUS IMM IV VIAL INJ, DALBAVANCIN, 5MG INJECTION, DAPTOMYCIN (HOSPIRA), 1 MG DAPTOMYCIN INJECTION INJECTION, DIFELIKEFALIN, 0.1 MICROGRAM Auth Required Auth Not Required Auth Not Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Not Required Plan Exclusion. Refer to plan document to verify if plan exclusion. Contact Customer Service for benefit coverage. Auth Not Required Not Covered Auth Not Required Not Covered* Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Required Not Covered Auth Not Required Auth Not Required Not Covered 9 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J0881 J0882 J0883 J0884 J0885 J0887 J0888 J0890 J0891 J0892 J0893 J0894 J0895 J0896 J0897 J0898 J0899 J0945 J1000 J1020 J1030 J1040 J1050 J1071 J1094 J1095 J1096 J1097 J1100 J1110 J1120 J1130 J1160 DARBEPOTIN ALFA INJ 1 MCG DARBEPO ALFA INJ ESRD 1MCG INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE) INJECTION, ARGATROBAN, 1 MG (FOR ESRD ON DIALYSIS) EPOETIN ALFA (NON ESRD)1000 UNITS INJ, EPOETIN BETA, 1 MICROGRAM, (FOR ESRD ON DIALYSIS) INJECTIN, EPOETIN BETA, 1 MICROGRAM, (FOR NON ESRD USE) INJECTION, PEGINESATIDE, 0. 1 MG (FOR ESRD ON DIALYSIS) INJECTION, ARGATROBAN (ACCORD), 1 MG (FOR NON-ESRD USE) INJECTION, ARGATROBAN (ACCORD), 1 MG (FOR ESRD ON DIALYSIS) INJECTION, DECITABINE (SUN PHARMA), 1 MG DECITABINE INJ, 1MG DEFEROX MESY 500MG PER 5CC INJ INJECTION, LUSPATERCEPT-AAMT, 0.25 MG INJ, DENOSUMAB, 1 MG INJECTION, ARGATROBAN (AUROMEDICS), 1 MG (FOR NON-ESRD USE) INJECTION, ARGATROBAN (AUROMEDICS), 1 MG (FOR ESRD ON DIALYSIS) BROMPHENIRAMINE MAL 10MG INJ DEPO ESTRADIOL CYPI 5MG INJ METHYLPREDNISOLONE 20 MG INJ METHYLPREDNISOLONE 40 MG INJ METHYLPRED ACETATE 80MG INJ INJ, MEDROXYPROGESTERONE ACETATE, 1 MG INJ, TESTOSTERONE CYPIONATE, 1MG DEXAMETHASONE ACETATE 1 MG INJ INJECTION, DEXAMETHASONE 9% DEXAMETHASONE, OPTH INSERT, 0.1 MG PHENYLEPHRINE 10.16 MG/ML AND KETOROLAC 2.88 MG/ML OPHTH IRRIGATION SOL, 1 ML DEXAMETHASONE SOD PHOS 1MG DIHYDROERGOTAMINE INJECTION 1MG ACETAZOLAMID SODIUM INJECTIO INJ, DICLOFENAC SODIUM, 0.5 MG DIGOXIN INJECTION Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Not Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Not Covered Not Covered Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required 10 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J1162 J1165 J1170 J1180 J1190 J1200 J1201 J1205 J1212 J1230 J1240 J1245 J1250 J1260 J1265 J1267 J1270 J1290 J1300 J1301 J1302 J1303 J1305 J1306 J1320 J1322 J1324 J1325 J1327 J1330 J1335 J1364 J1380 DIGOXIN IMMUNE FAB (OVINE) PHENYTOIN SODIUM INJECTION HYDROMORPHONE INJECTION DYPHYLLINE INJECTION DEXRAZOXANE HCL INJECTION 250 MG DIPHENHYDRAMINE HCL UP TO 50MG INJECTION, CETIRIZINE HYDROCHLORIDE, 0.5 MG CHLOROTHIAZIDE SODIUM INJ DIMETHYL SULFOXIDE 50% 50 ML METHADONE INJECTION DIMENHYDRINATE INJECTION DIPYRIDAMOLE INJECTION DOBUTAMINE HCL,PER 250 MG DOLASETRON MESYLATE 10MG INJ DOPAMINE INJECTION DORIPENEM 10MG INJ DOXERCALCIFEROL, 1 MCG INJ ECALLANTIDE 1 MG INJECTION ECULIZUMAB 10MG INJ INJ, EDARAVONE, 1 MG INJECTION, SUTIMLIMAG-JOME, 10 MG INJ, RAVULIZUMAB-CWVZ, 10 MG INJ, EVINACUMAB-DGNB, 5MG INJECTION, INCLISIRAN, 1 MG AMITRIPTYLINE INJECTION INJ, ELOSULFASE ALFA, 1MG ENFUVIRTIDE INJ, 1MG EPOPROSTENOL,0.5 MG EPTIFIBATIDE 5MG INJ ERGONOVINE MALEATE INJECTION ERTAPENEM SODIUM 500MG ERYTHRO LACTOBIONATE /500 MG ESTRADIOL VALERATE 10 MG INJ Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Auth Required Auth Required Not Covered* Auth Required Auth Not Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required 11 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J1410 J1426 J1427 J1428 J1429 J1430 J1435 J1436 J1437 INJ ESTROGEN CONJUGATE 25 MG INJ, CASIMERSEN, 10 MG INJECTION, VILTOLARSEN, 10 MG INJ, ETEPLIRSEN, 10 MG INJECTION, GOLODIRSEN, 10 MG ETHANOLAMINE OLEATE 100 MG INJECTION ESTRONE PER 1 MG ETIDRONATE DISODIUM INJ INJECTION, FERRIC DERISOMALTOSE, 10 MG J1438 ETANERCEPT 25MG INJ J1439 J1442 J1443 J1444 J1445 J1447 J1448 J1450 J1451 J1452 J1453 J1454 J1455 J1456 J1457 J1458 J1459 J1460 J1551 J1554 J1555 INJ, FERRIC CARBOXYMALTOSE, 1MG INJECTION FILGRASTIM G-CSF 1 MICROGRAM INJ, FERRIC PYROPHOSPHATE CITRATE SOLUTION, 0.1 MG OF IRON INJ, FERRIC PYROPHOSPHATE CITRATE POWDER, 0.1 MG OF IRON INJ. FERRIC PYROPHOSPHATE CIT SOL 0.1 MG OF IRON INJ, TBO-FILGRASTIM, 1 MICROGRAM INJ, TRILACICLIB, 1MG FLUCONAZOLE 200MG INJ FOMEPIZOLE, 15 MG FOMIVIRSEN SOD INTRAOC 1.65 MG FOSAPREPITANT 1MG INJ INJ, FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG FOSCARNET SODIUM 1,000MG INJ INJECTION, FOSAPREPITANT (TEVA), 1 MG GALLIUM NITRATE INJECTION GALSULFASE INJ, 1MG IMMUNE GLOBULIN 500MG INJ GAMMA GLOBULIN 1 CC INJ INJECTION, IMMUNE GLOBULIN (CUTAQUIG), 100 MG INJECTION, IMMUNE GLOBULIN (ASCENIV), 500 MG INJ, IMMUNE GLOBULIN (CUVITRU), 100 MG Auth Not Required Not Covered* Not Covered Not Covered Not Covered Auth Not Required Auth Not Required Auth Not Required Auth Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Required Not Covered Auth Required Not Covered No Auth Required Auth Not Required Not Covered* Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Not Covered Not Covered Auth Required 12 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J1556 J1557 J1558 J1559 J1560 J1561 J1562 J1566 J1568 J1569 J1570 J1571 J1572 J1573 J1574 J1575 J1580 J1595 J1599 J1600 J1602 J1610 J1611 J1620 J1626 J1627 INJECTION IMMUNE GLOBULIN BIVIGAM 500 MG INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), IV, NON-LYOPHILIZED (E.G. INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 MG HIZENTRA 100 MG INJECTION GAMMA GLOBULIN 10 CC INJ IMMUNE GLOBULIN IV 500MG IMMUNE GLOBULIN INJ 1000MG IMMUNE GLOBULIN, POWDER OCTAGAM INJECTION GAMMAGARD LIQUID INJECTION GANCICLOVIR SODIUM 500MG INJ HEPAGAM B IM INJECTION IMMUNE GLOBULIN IV 500MG,NONLYOPHILIZED HEPAGAM B INTRAVENOUS, INJ INJECTION, GANCICLOVIR SODIUM (EXELA), 500 MG INJ, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN GARAMYCIN GENTAMICIN 80MG INJ INJECTION GLATIRAMER ACETATE IVIG NON-LYOPHILIZED 500 MG IV GOLD SOD THIOMALEATE 50MG INJ INJECTION GOLIMUMAB 1 MG FOR INTRAVENOUS USE GLUCAGON HYDROCHLOR 1 MG INJ INJECTION, GLUCAGON HYDROCHLORIDE (FRESENIUS KABI), PER 1 MG GONADORELIN HYDRO 100 MCG INJ GRANISETRON HCL 100 MCG INJ, GRANISETRON, EXTENDED-RELEASE, 0.1 MG J1628 INJ, GUSELKUMAB, 1 MG J1630 J1631 J1632 J1640 HALOPERIDOL UP TO 5MG INJ HALOPERIDOL DECANOATE 50MG INJ INJECTION, BREXANOLONE, 1 MG INJ, HEMIN, 1 MG Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Not Covered Auth Not Required Auth Required Auth Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Not Required Auth Not Required Auth Required Auth Required 13 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J1642 J1643 J1644 J1645 J1650 J1652 J1655 J1670 J1675 J1700 J1710 J1720 HEPARIN SODIUM 10 UNITS INJ INJECTION, HEPARIN SODIUM (PFIZER), PER 1000 UNITS HEPARIN SODIUM PER 1000U INJ DALTEPARIN SODIUM PER 2500 IU ENOXAPARIN SODIUM 10 MG INJ FONDAPARINUX SOD 0.5MG INJ TINZAPARIN SODIUM,1000 IU INJ TETANUS IMM GLOB TO 250MG INJ HISTRELIN ACETATE HYDROCORTISONE ACET 25MG INJ HYDROCORTISONE SOD PH 50MG INJ HYDROCORT SOD SUCC 100MG INJ J1726 INJ, HYDROXYPROGESTERONE CAPROATE, (MAKENA), 10 MG J1729 J1730 J1738 J1740 J1741 J1742 J1743 J1744 J1745 J1746 J1750 J1756 J1786 J1790 J1800 J1810 J1815 J1817 INJECTION, HYDROXYPROGESTERONE CAPROATE, NOS, 10 MG DIAZOXIDE UP TO 300MG INJ INJECTION, MELOXICAM, 1 MG IBANDRONATE SODIUM INJ, 1MG INJ, IBUPROFEN, 100 MG IBUTILIDE FUMARATE 1 MG INJ IDURSULFASE INJECTION INJ, ICATIBANT, 1 MG INFLIXIMAB 10MG INJ INJ, IBALIZUMAB-UIYK, 10 MG IRON DEXTRAN 50MG INJ IRON SUCROSE 1 MG INJ IMUGLUCERASE 10 UNIT INJECTION DROPERIDOL INJ UP TO 5MG PROPRANOLOL HCL TO 1MG INJ DROPER FENTANYL CIT TO 2ML AMP INSULIN PER 5 UNITS INJ INSULIN ADM THROUGH DME/50 UN Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Not Required Auth Not Required Auth Not Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Required Auth Not Required Not Covered Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required 14 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J1823 INJECTION, INEBILIZUMAB-CDON, 1 MG J1826 INTERFERON BETA-1A 30MCG INJ J1830 INTERFERON BETA 1B 0.25 MG J1833 J1835 J1840 J1850 J1885 J1890 J1930 J1931 J1932 J1940 J1943 J1944 J1945 J1950 J1951 J1952 J1953 J1955 J1956 J1960 J1980 J1990 J2001 J2010 J2020 INJ, ISAVUCONAZONIUM, 1 MG ITRACONAZOLE, 50 MG INJ KANAMYCIN SULFATE 500 MG INJ KANAMYCIN SULFATE 75 MG INJ KETOROLAC TROM PER 15MG INJ CEPHALOTHIN SODIUM TO 1G INJ IANREOTIDE 1MG INJ LARONIDASE INJECTION INJECTION, LANREOTIDE, (CIPLA), 1 MG FUROSEMIDE TO 20MG INJ INJ, ARIPIPRAZOLE LAUROXIL, (ARISTADA INITIO), 1 MG INJ, ARIPIPRAZOLE LAUROXIL, (ARISTADA), 1 MG LEPIRUDIN LEUPROLIDE ACETATE 3.75MG INJ INJECTION, LEUPROLIDE ACETATE FOR DEPOT SUSPENSION (FENSOLVI), 0.25 MG LEUPROLIDE INJECTABLE, CAMCEVI, 1 MG LEVETIRACETAM 10MG INJ LEVOCARNITINE PER 1G INJ LEVOFLOXACIN 250MG INJ LEVORPHANOL TARTRATE 2MG INJ HYOSCYAMINE SULF 0.25MG INJ CHLORDIAZEPOXIDE HCL 100MG INJ LIDOCAINE HCI IV,10 MG, INJ LINCOMYCIN HCL 300MG INJ INJ, LINEZOLID, 200 MG Auth Required Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Not covered under medical benefit. Contact RealRx pharmacy customer service for benefit coverage. Auth Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Required Auth Required Auth Required Auth Not Required Auth Required Auth Required Auth Not Required Auth Required Not Covered Not Covered* Auth Not Required Not Covered Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required Auth Not Required 15 This Medical Pharmacy code list is updated regularly, and the Health Plan reserves the right to amend these policies and give notice in accordance with State and Federal requirements. Effective 01/01/2023

J2021 J2060 J2062 J2150 INJECTION, LINEZOLID (HOSPIRA), 200 MG LORAZEPAM 2MG INJ LOXAPINE, INHALATION, 1 MG MANNITOL 25% IN 50ML INJ J2170 MECASERMIN INJ, 1MG J2175 J2180 J2182 J2184 J2185 J2186 J2210 J2212 J2247 J2248 J2250 J2251 J2260 J2265 J2270 J2272 J2274 J2278 J2280 J2281 J2300 J2310 J2311 J2315 J2320 J2323 MEPERIDINE HYDROCHL 100MG INJ MEPERIDINE PROM HCL 50MG INJ INJ, MEPOLIZUMAB, 1 MG INJECTION, MEROPENEM (B. BRAUN), 100 MG MEROPENEM INJ, MEROPENEM AND VABORBACTAM, 10MG/10MG (20MG) METHYLERGONOVIN MAL 0.2MG INJ INJECTION, METHYLNALTREXONE, 0. 1 MG INJECTION, MICAFUNGIN SODIUM (PAR PHARM), 1 MG MICAFUNGIN SODIUM INJ,1MG MIDAZOLAM HCL PER 1 MG INJ INJECTION, MIDAZOLAM HYDROCHLO

This Medical Pharmacy code list is updated regularly, and the Health Plan reservesthe right to amend these policies and give notice in accordance with State and Federal requirements. . For questions regarding retail pharmacy please call RealRx pharmacy customer service: Individual & Family Plans: 855-869-4769, Commercial Groups: 855-509-8142. .

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