Injection, factor viii (antihemophilic factor, recombinant) Afstyla AvMed Novologix. Sildenafil citrate, 25 mg Revatio Novologix Novologix
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1 90284 or J J0129 MEDICATIONAUTHORIZATIONWORKFLOWFORDRUGSTHATREQUIREPRIOR-AUTHORIZATION (06/9/17) BASEDONLOCATIONWHEREDRUGWILLBEADMINISTERED J-code Medication Drug Name Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each Respiratory syncytial virus immune globulin (RSV-IgIM), for intramuscular use, 50 mg, each HIZENTRA SYNAGIS Injection, factor viii (antihemophilic factor, recombinant) Afstyla AvMed Injection, atezolizumab, 10 mg TECENTRIQ Sildenafil citrate, 25 mg Revatio Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug ORENCIA J0202 Injection, alemtuzumab, 1 mg LEMTRADA J0256 Injection, alpha 1 proteinase inhibitor (human),, 10 mg Aralast NP J0256 Injection, alpha 1 proteinase inhibitor (human),, 10 mg Prolastin-C J0256 Injection, alpha 1 proteinase inhibitor (human),, 10 mg Zemaira J0257 Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg GLASSIA J0490 Injection, belimumab, 10 mg BENLYSTA J0570 BUPRENORPHINE IMPLANT, 74.2 MG PROBUPHINE J0585 Injection, onabotulinumtoxina, 1 unit BOTOX J0586 Injection, abobotulinumtoxina, 5 units DYSPORT J0587 Injection, rimabotulinumtoxinb, 100 units MYOBLOC J0588 Injection, incobotulinumtoxin a, 1 unit XEOMIN J0596 Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units RUCONEST J0598 Injection, c-1 esterase inhibitor (human), cinryze, 10 units CINRYZE J0638 Injection, canakinumab, 1 mg ILARIS J0641 Injection, levoleucovorin calcium, 0.5 mg FUSILEV J0717 DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, (NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) CIMZIA J0800 Injection, corticotropin, up to 40 units Acthar HP J0800 Injection, corticotropin, up to 40 units HP Acthar J0881 Injection, darbepoetin alfa, 1 microgram (non-esrd use) Aranesp (Albumin Free) J0882 Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) Aranesp (Albumin Free) J0885 Injection, epoetin alfa, (for non-esrd use), 1000 units Epogen J0885 Injection, epoetin alfa, (for non-esrd use), 1000 units Procrit J1290 Injection, ecallantide, 1 mg KALBITOR
2 J1300 Injection, eculizumab, 10 mg SOLIRIS J1322 Injection, elosulfase alfa, 1 mg VIMIZIM J1325 Injection, epoprostenol, 0.5 mg Epoprostenol Sodium J1325 Injection, epoprostenol, 0.5 mg Flolan J1325 Injection, epoprostenol, 0.5 mg Veletri J1442 Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram NEUPOGEN J1447 Injection, tbo-filgrastim, 1 microgram GRANIX J1459 Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg PRIVIGEN J1556 Injection, immune globulin (bivigam), 500 mg Bivigam J1557 J1559 or J1561 J1566 J1566 J1568 J1569 J1572 J1575 Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg Gammaplex Injection, immune globulin (hizentra), 100 mg HIZENTRA Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg Injection, immune globulin, intravenous, lyophilized (e.g., powder),, 500 mg Injection, immune globulin, intravenous, lyophilized (e.g., powder),, 500 mg Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g. liquid), 500 mg Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, nonlyophilized (e.g., liquid), 500 mg Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin Gammaked Carimune NF Gammagard S/D Less IgA Octagam Gammagard Flebogamma DIF HYQVIA J1602 Injection, golimumab, 1 mg, for intravenous use SIMPONI ARIA J1744 Injection, icatibant, 1 mg FIRAZYR J1745 Injection, infliximab, excludes biosimilar, 10 mg REMICADE J1786 Injection, imiglucerase, 10 units CEREZYME J2182 INJECTION, MEPOLIZUMAB, 1 MG NUCALA J2323 Injection, natalizumab, 1 mg TYSABRI J2357 Injection, omalizumab, 5 mg XOLAIR J2469 Injection, palonosetron hcl, 25 mcg Aloxi J2505 Injection, pegfilgrastim, 6 mg NEULASTA J2507 Injection, pegloticase, 1 mg KRYSTEXXA J2786 INJECTION, RESLIZUMAB, 1 MG CINQAIR J2796 Injection, romiplostim, 10 micrograms NPLATE
3 J2820 Injection, sargramostim (gm-csf), 50 mcg LEUKINE J2840 INJECTION, SEBELIPASE ALFA, 1 MG KANUMA J2860 Injection, siltuximab, 10 mg SYLVANT J3060 Injection, taliglucerace alfa, 10 units ELELYSO J3262 Injection, tocilizumab, 1 mg ACTEMRA J3285 Injection, treprostinil, 1 mg REMODULIN J3315 Injection, triptorelin pamoate, 3.75 mg TRELSTAR J3357 Ustekinumab, for subcutaneous injection, 1 mg STELARA J3380 Injection, vedolizumab, 1 mg ENTYVIO J3385 Injection, velaglucerase alfa, 100 units VPRIV Unclassified Medication AvMed AvMed J3590 Unclassified Medication AvMed AvMed J7175 INJECTION, FACTOR X, (HUMAN), 1 I.U. COAGADEX AvMed J7179 J7182 INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VONVENDI), 1 I.U. VWF:RCO Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu VONVENDI NOVOEIGHT AvMed J7183 Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco Wilate J7185 Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. XYNTHA J7186 Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. Alphanate/ VWF Complex/Human J7187 Injection, von willebrand factor complex (humate-p), per iu vwf:rco HUMATE-P J7188 Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. Obizur J7189 Factor viia (antihemophilic factor, recombinant), per 1 microgram NovoSeven RT J7190 Factor viii (antihemophilic factor, human) per i.u. HEMOFIL M J7190 Factor viii (antihemophilic factor, human) per i.u. Koate-DVI J7190 Factor viii (antihemophilic factor, human) per i.u. MONOCLATE-P ADVATE Helixate FS Kogenate FS RECOMBINATE J7193 Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. AlphaNine SD J7193 Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. Mononine
4 J7194 Factor ix, complex, per i.u. BEBULIN J7194 Factor ix, complex, per i.u. PROFILNINE J7195 J7195 Injection, factor ix (antihemophilic factor, recombinant) per iu, Injection, factor ix (antihemophilic factor, recombinant) per iu, BeneFIX Ixinity J7198 Anti-inhibitor, per i.u. FEIBA J7199 Eloctate (antihemophilic factor) Eloctate J7200 Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu Rixubis J7201 Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. ALPROLIX J7202 INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (RECOMBINANT), IDELVION, 1 I.U. Idelvion AvMed AvMed J7205 Injection, factor viii fc fusion (recombinant), per iu ELOCTATE J7207 J7209 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PEGYLATED, 1 I.U. Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. ADYNOVATE AvMed AvMed Nuwiq J9015 Injection, aldesleukin, per single use vial PROLEUKIN J9019 Injection, asparaginase (erwinaze), 1,000 iu ERWINAZE J9032 Injection, belinostat, 10 mg BELEODAQ J9034 INJECTION, BENDAMUSTINE HCL (BENDEKA), 1 MG Bendeka AvMed AvMed J9039 Injection, blinatumomab, 1 microgram BLINCYTO J9042 Injection, brentuximab vedotin, 1 mg ADCETRIS J9043 Injection, cabazitaxel, 1 mg JEVTANA J9047 Injection, carfilzomib, 1 mg KYPROLIS J9055 Injection, cetuximab, 10 mg ERBITUX J9145 INJECTION, DARATUMUMAB, 10 MG Darzalex J9176 INJECTION, ELOTUZUMAB, 1 MG Empliciti J9179 Injection, eribulin mesylate, 0.1 mg HALAVEN J9205 INJECTION, IRINOTECAN LIPOSOME, 1 MG Onivyde J9214 Injection, interferon, alfa-2b, recombinant, 1 million units INTRON A J9217 Leuprolide acetate (for depot suspension), 7.5 mg LUPRON DEPOT J9217 Leuprolide acetate (for depot suspension), 7.5 mg LUPRON DEPOT-PED J9226 Histrelin implant (supprelin la), 50 mg Supprelin LA J9228 Injection, ipilimumab, 1 mg YERVOY
5 J9262 Injection, omacetaxine mepesuccinate, 0.01 mg SYNRIBO J9264 Injection, paclitaxel protein-bound particles, 1 mg ABRAXANE J9266 Injection, pegaspargase, per single dose vial ONCASPAR J9271 Injection, pembrolizumab, 1 mg KEYTRUDA J9293 Injection, mitoxantrone hydrochloride, per 5 mg Mitoxantrone HCl J9299 Injection, nivolumab, 1 mg OPDIVO J9301 Injection, obinutuzumab, 10 mg GAZYVA J9303 Injection, panitumumab, 10 mg VECTIBIX J9305 Injection, pemetrexed, 10 mg ALIMTA J9306 Injection, pertuzumab, 1 mg PERJETA J9308 Injection, ramucirumab, 5 mg CYRAMZA J9310 Injection, rituximab, 100 mg RITUXAN J9325 INJECTION, TALIMOGENE LAHERPAREPVEC, PER 1 MILLION PLAQUE FORMING UNITS IMLYGIC J9352 INJECTION, TRABECTEDIN, 0.1 MG YONDELIS J9354 Injection, ado-trastuzumab emtansine, 1 mg KADCYLA J9355 Injection, trastuzumab, 10 mg HERCEPTIN J9400 Injection, ziv-aflibercept, 1 mg ZALTRAP J9999 Unclassified Chemotherapy Medication AvMed AvMed Q2043 Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with papgm-csf, including leukapheresis and all other preparatory procedures, per infusion PROVENGE Q4081 Injection, epoetin alfa, 100 units (For ESRD on dialysis) Epogen Q4081 Injection, epoetin alfa, 100 units (For ESRD on dialysis) Procrit Q5101 Injection, filgrastim (g-csf), biosimilar, 1 microgram ZARXIO
MEDICATION AUTHORIZATION WORKFLOW FOR DRUGS THAT REQUIRE PRIOR-AUTHORIZATION (03/23/18) BASED ON LOCATION WHERE DRUG WILL BE ADMINISTERED
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