X.242 OptimizeRx (excluding Armor Health prefixes YXN and YDB)
OptimizeRx (excluding Armor Health prefixes YXN and YDB)
X.242
X.242 OptimizeRx (excluding Armor Health prefixes YXN and YDB)
Please submit PA requests directly to GatewayPA.
- Hours of Operation: 24 hours a day
- Call toll free: 1-800-424-1709 or fax 1-888-656-6671
- Website: GatewayPA.com
Please submit PA requests directly to GatewayPA.
• Hours of Operation: 24 hours a day
• Call toll free: 1-800-424-1709 or fax 1-888-656-6671
• Website: GatewayPA.com
Prior authorization is not a guarantee of payment. Benefits are based on eligibility at the
time of service and are subject to applicable contract terms.
For more information, please review the BCBSNE Provider Procedures searchable tool
on NebraskaBlue.com/Providers/BCBSNE-Provider-Procedures.
Dates
-
Original Effective
09-30-2025
-
Last Review
11-05-2025
-
Next Review
11-05-2026
Reference Table
|
HCPCS |
NDC |
BRAND NAME |
GENERIC NAME |
|
Q2055 |
|
Abecma |
idecabtagene vicleucel |
|
J9264 |
|
Abraxane |
paclitaxel protein-bound |
|
J3262 |
|
Actemra IV |
tocilizumab |
|
J0801 |
|
Acthar_HP |
corticotropin |
|
J9216 |
|
Actimmune |
interferon gamma-1b |
|
J0791 |
|
Adakveo |
crizanlizumab-tmca |
|
J9042 |
|
Adcetris |
brentuximab vedotin |
|
J9029 |
|
Adstiladrin |
nadofaragene firadenovec-vncg |
|
J7192 |
|
Advate |
antihemophilic factor (recombinant) |
|
J7207 |
|
Adynovate |
antihemophilic factor (recombinant), pegylated |
|
J7171 |
|
Adzynma |
ADAMTS13, recombinant-krhn |
|
J7210 |
|
Afstyla |
antihemophilic factor (recombinant), single chain |
|
Q5150 |
|
Ahzantive |
aflibercept-mrbb |
|
J1454 |
|
Akynzeo IV |
fosnetupitant/palonosetron |
|
J1931 |
|
Aldurazyme |
laronidase |
|
J7173 |
|
Alhemo |
concizumab-mtci |
|
J7186 |
|
Alphanate |
antihemophilic factor/von willebrand factor complex (human) |
|
J7193 |
|
Alphanine SD |
coagulation factor ix (human) |
|
J7201 |
|
Alprolix |
coagulation factor ix (recombinant), fc fusion protein |
|
J7214 |
|
Altuviiio |
antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl |
|
J1552 |
|
Alyglo |
intravenous immune globulin |
|
Q5126 |
|
Alymsys |
bevacizumab-maly |
|
J0215 |
|
Amevive |
alefacept |
|
J1426 |
|
Amondys-45 |
casimersen |
|
J9999/C9399 |
73776-0001-11 |
Amtagvi |
lifileucel |
|
J0225 |
|
Amvuttra |
vutrisiran |
|
J9028 |
|
Anktiva |
nogapendekin alfa inbakicept-pmln |
|
J8502 |
|
Aponvie |
aprepitant |
|
J0256 |
|
Aralast NP |
alpha-1-proteinase inhibitor |
|
J0881 |
|
Aranesp |
darbepoetin |
|
J2793 |
|
Arcalyst |
rilonacept |
|
Q5169 |
|
Armlupeg |
pegfilgrastiim-unne |
|
J1554 |
|
Asceniv |
intravenous immune globulin |
|
J7504 |
|
Atgam |
lymphocyste immune globulin |
|
Q2058 |
|
Aucatzyl |
obecabtagene autoleucel |
|
Q5161 |
|
Aukelso |
denosumab-kyqq |
|
J9035 |
|
Avastin |
bevacizumab |
|
J9184 |
|
Avgemsi |
gemcitabine |
|
J1757 |
|
Avlayah |
tividenofusp alfa-eknm |
|
Q5121 |
|
Avsola |
infliximab-axxq |
|
Q5156 |
|
Avtozma IV Only |
Tocilizumab-anoh |
|
J9999/C9399 |
82143-0001-01 |
Avzivi |
Bevacizumab-tnjn |
|
J9292 |
|
Axtle |
pemetrexed (avyxa) |
|
J9066 |
|
|
bendamustine hydrochloride |
|
A9590 |
|
Azedra |
iobenguane I 131 |
|
J9023 |
|
Bavencio |
avelumab |
|
J9036 |
|
Belrapzo |
bendamustine |
|
J9036 |
|
bendamustine (Apotex) |
bendamustine hydrochloride |
|
J9036 |
|
bendamustine (Baxter) |
bendamustine hydrochloride |
|
J9999/C9399 |
43598-0049-11 |
Bendamustine (Dr. Reddy's) |
Bendamustine |
|
J9034 |
|
Bendeka |
bendamustine |
|
J7195 |
|
BeneFIX |
coagulation factor ix (recombinant) |
|
J0490 |
|
Benlysta IV |
belimumab |
|
J0179 |
|
Beovu |
brolucizumab-dbll |
|
J1414 |
|
Beqvez |
fidanacogene elaparvovec-dzkt |
|
J0597 |
|
Berinert |
c1 inhibitor (human) |
| Q5162 |
|
Bildyos |
denosumab-nxxp |
| Q5162 |
Bilprevda |
denosumab-nxxp |
|
|
J1556 |
|
Bivigam |
intravenous immune globulin |
|
J9382 |
|
Bizengri |
zenocutuzumab-zbco |
|
Q5152 |
|
Bkemv |
eculizumab-aeeb |
| J9053 |
|
Blenrep |
belantamab mafodotin-blmf |
|
J9039 |
|
Blincyto |
blinatumomab |
|
Q5158 |
|
Bomyntra |
denosumab-bnht |
| Q5171 |
Boncresa |
denosumab-mobz | |
| Q5161 |
Bosaya |
denosumab-kyqq |
|
|
J0585 |
|
Botox |
onabotulinumtoxina |
|
Q2054 |
|
Breyanzi |
lisocabtagene maraleucel |
|
J0567 |
|
Brineura |
cerliponase alfa |
|
J2329 |
|
Briumvi |
ublituximab-xiiy |
|
Q5124 |
|
Byooviz |
ranibizumab-nuna |
|
J9064 |
|
Cabazitaxel |
cabazitaxel (Sandoz) |
|
J1952 |
|
Camcevi |
leuprolide mesylate (for depot emulsion) |
|
J9003 |
|
Camcevi ETM |
leuprolide mesylate |
|
Q2056 |
|
Carvykti |
ciltacabtagene autoleucel |
|
J3392 |
|
Casgevy |
exagamglogene autotemcel |
|
J0205 |
|
Ceredase |
alglucerase |
|
J1786 |
|
Cerezyme |
imiglucerase |
|
Q5128 |
|
Cimerli |
ranibizumab-eqrn |
|
J0717 |
|
Cimzia |
certolizumab pegol |
|
J2786 |
|
Cinqair |
reslizumab |
|
J0598 |
|
Cinryze |
c1 inhibitor (human) |
|
J9286 |
|
Columvi |
glofitamab-gxbm |
|
Q5158 |
|
Conexxence |
denosumab-bnht |
|
J0802 |
|
Cortrophin |
repository corticotropin |
|
J1448 |
|
Cosela |
trilaciclib |
|
J3247 |
|
Cosentyx IV |
secukinumab |
|
J0584 |
|
Crysvita |
burosumab-twxa |
|
J1551 |
|
Cutaquig |
subcutaneous immune globulin |
|
J1555 |
|
Cuvitru |
subcutaneous immune globulin |
|
J9308 |
|
Cyramza |
ramucirumab |
|
J9348 |
|
Danyelza |
naxitamab |
|
J9145 |
|
Darzalex |
daratumumab |
|
J9144 |
|
Darzalex Faspro |
daratumumab+hyaluronidase-fihj |
|
J9011 |
|
Datroway |
datopotamab deruxtecan-dlnk |
|
J0589 |
|
Daxxify |
daxibotulinumtoxinA-lanm |
|
C9313 |
|
Decnupaz |
pivekimab sunirine-pvzy |
|
J7318 |
|
Durolane |
hyaluronan or derivative |
|
J0586 |
|
Dysport |
abobotulinumtoxina |
|
Q5151 |
|
Eculizumab-aagh |
eculizumab-aagh |
|
J9063 |
|
Elahere |
mirvetuximab soravtansine-gynx |
|
J1743 |
|
Elaprase |
idursulfase |
|
J3060 |
|
Elelyso |
taliglucerase alfa |
|
J1413 |
|
Elevidys |
delandistrogene moxeparvovec-rokl |
|
J2508 |
|
Elfabrio |
pegunigalsidase alfa-iwxj-dlwr |
|
J9217 |
|
Eligard |
leuprolide acetate (for depot suspension) |
|
J7205 |
|
Eloctate |
antihemophilic factor (recombinant), fc fusion protein |
|
J1323 |
|
Elrexfio |
elranatamab-bcmm |
|
J9269 |
|
Elzonris |
tagraxofusp-erzs |
|
J9326 |
|
Emrelis |
telisotuzumab vedotin-tllv |
|
J3403 |
|
Encelto |
revakinagene taroretcel-lwey |
|
J9358 |
|
Enhertu |
fam-trastuzumab deruxtecan-nxki |
|
J1302 |
|
Enjaymo |
sutimlimab-jome |
| Q5167 |
|
Enoby |
denosumab-qpde |
|
J3590/C9399 |
50242-0007-01 |
Enspryng |
satralizumab-mwge |
|
J3380 |
|
Entyvio IV |
vedolizumab |
|
Q5149 |
|
Enzeevu |
aflibercept-abzv |
|
J9321 |
|
Epkinly |
epcoritamab-bysp |
|
Q5151 |
|
Epysqli |
eculizumab-aagh |
|
J9055 |
|
Erbitux |
cetuximab |
|
J7204 |
|
Esperoct |
antihemophilic factor (recombinant), fc fusion protein |
|
J7323 |
|
Euflexxa |
hyaluronan or derivative |
|
C9312/J9362 |
|
EVDI |
trabectedin |
|
J3111 |
|
Evenity |
romosozumab-aqqg |
|
J1305 |
|
Evkeeza |
evinacumab-dgnb |
|
J9246 |
|
Evomela |
melphalan |
|
J2361 |
|
Exdensur |
depemokimab-ulaa |
|
J1428 |
|
Exondys-51 |
eteplirsen |
| Q5170 |
|
Eydenzelt |
aflibercept-boav |
|
J0178 |
|
Eylea |
aflibercept |
|
J0177 |
|
Eylea HD |
aflibercept |
|
J0180 |
|
Fabrazyme |
agalsidase beta |
|
J0517 |
|
Fasenra |
benralizumab |
|
J1951 |
|
Fensolvi |
leuprolide acetate |
|
J1744 |
|
Firazyr |
icatibant |
|
J9155 |
|
Firmagon |
degarelix |
|
J1572 |
|
Flebogamma |
intravenous immune globulin |
|
Q5108 |
|
Fulphila |
pegfilgrastim-cbqv |
|
J0641 |
|
Fusilev |
levoleucovorin calcium |
|
J9331 |
|
Fyarro |
sirolimus-albumin-bound |
|
Q5130 |
|
Fylnetra |
pegfilgrastim-pbbk |
|
J9210 |
|
Gamifant |
emapalumab-lzsg |
|
J1569 |
|
Gammagard Liquid |
intravenous immune globulin |
|
J1599/C9399 |
00944-2705-50 |
Gammagard Liquid ERC IV only |
intravenous immune globulin |
|
J3590/C9399 |
00944-2705-50 |
Gammagard Liquid ERC SQ Only |
intravenous immune globulin |
|
J1566 |
|
Gammagard S/D |
intravenous immune globulin |
|
J1561 |
|
Gammaked |
intravenous immune globulin |
|
J1557 |
|
Gammaplex |
intravenous immune globulin |
|
J1561 |
|
Gamunex-C |
intravenous immune globulin |
|
J9301 |
|
Gazyva |
obinutuzumab |
|
J7326 |
|
Gel-One |
hyaluronan or derivative |
|
J7328 |
|
Gelsyn-3 |
hyaluronan or derivative |
|
J7320 |
|
Genvisc 850 |
hyaluronan or derivative |
|
J0223 |
|
Givlaari |
givosiran |
|
J0257 |
|
Glassia |
alpha-1-proteinase inhibitor |
|
J0599 |
|
Haegarda |
C1 Esterase Inhibitor Subcutaneous [Human] |
|
J9179 |
|
Halaven |
eribulin |
|
J1411 |
|
Hemgenix |
etranacogene dezaparvovec-drlb |
|
J7170 |
|
Hemlibra |
emicizumab-kxwh |
|
J7190 |
|
Hemofil M |
antihemophilic factor (human) |
|
J9355 |
|
Herceptin |
trastuzumab |
|
J9356 |
|
Herceptin Hylecta |
trastuzumab-hyaluronidase-oysk |
|
Q5146 |
|
Hercessi |
trastuzumab-strf |
|
Q5113 |
|
Herzuma |
trastuzumab-pkrb |
|
A9517 |
|
HICON (capsule formula) |
Sodium Iodide I 131 |
|
J1559 |
|
Hizentra |
subcutaneous immune globulin |
|
J7187 |
|
Humate-P |
antihemophilic factor/von willebrand factor complex (human) |
|
J7321 |
|
Hyalgan |
hyaluronan or derivative |
|
J7322 |
|
Hymovis |
hyaluronan or derivative |
|
J7172 |
|
Hympavzi |
marsctacimab-hncq |
|
J1575 |
|
Hyqvia |
subcutaneous immune globulin |
|
J7202 |
|
Idelvion |
coagulation factor ix (recombinant), albumin fusion protein |
|
J0638 |
|
Ilaris |
canakinumab |
|
J3245 |
|
Ilumya |
tildrakizumab-asmn |
|
J9256 |
Imaavy |
nipocalimab-aahu |
|
|
J9026 |
|
Imdelltra |
tarlatamab-dlle |
|
J9173 |
|
Imfinzi |
durvalumab |
|
J9347 |
|
Imjudo |
tremelimumab-actl |
|
Q5098 |
|
Imuldosa IV Only |
ustekinumab-ttwe |
|
Q5103 |
|
Inflectra |
infliximab-dyyb |
|
J1745 |
|
Infliximab unbranded |
infliximab |
|
J9198 |
|
Infugem |
gemcitabine |
|
J1439 |
|
Injectafer |
ferric carboxymaltose |
|
J9183 |
Inlexzo |
gemcitabine |
|
|
J1599 |
|
Intravenous Immune Globulin |
intravenous immune globulin |
|
J9319 |
|
Istodax |
romidepsin |
|
J3405 |
|
Itvitsma |
onasemnogene abeparvovac-brve |
|
J7213 |
|
Ixinity |
coagulation factor ix (recombinant) |
|
J2782 |
|
Izervay |
avacincaptad pegol |
|
J9281 |
|
Jelmyto |
mitomycin |
|
J9272 |
|
Jemperli |
dostarlimab-gxly |
|
J9043 |
|
Jevtana |
cabazitaxel |
|
J7208 |
|
Jivi |
antihemophilic factor (recombinant), PEGylated-aucl |
|
Q5160 |
|
Jobevne |
bevacizumab-nwgd |
|
Q5136 |
|
Jubbonti |
denosumab-bbdz |
|
Q5166 |
|
Jubereq/Osvyrti |
denosumab-desu |
|
J9354 |
|
Kadcyla |
ado-trastuzumab emtansine |
|
J1290 |
|
Kalbitor |
ecallantide |
|
Q5117 |
|
Kanjinti |
trastuzumab-anns |
|
J2840 |
|
Kanuma |
sebelipase alfa |
|
J3590/C9399 |
52856-0601-01 |
Kebilidi |
eladocagene exuparvovec-tneq |
|
J9271 |
|
Keytruda |
pembrolizumab |
| J9277 |
Keytruda Qlex |
pembrolizumab and berahyaluronidase alfa-pmph |
|
|
J0642 |
|
Khapzory |
levoleucovorin sodium |
|
J9274 |
|
Kimmtrak |
tebentafusp-tebn |
|
J0175 |
|
Kisunla |
donanemab-azbt |
|
J7190 |
|
Koate |
antihemophilic factor (human) |
|
J7211 |
|
Kovaltry |
antihemophilic factor (recombinant) |
|
C9399/J3590 |
83537-034-01 |
Kresladi |
marnetegragene autotemcel) |
|
J2507 |
|
Krystexxa |
pegloticase |
|
Q2042 |
|
Kymriah |
tisagenlecleucel |
|
J9047 |
|
Kyprolis |
carfilzomib |
|
J9278 |
|
Kyxata |
carboplatin |
|
J0217 |
|
Lamzede |
VELMANASE ALFA-TYCV |
|
C9399/J3590 |
73539000101, 73539000201 |
Lantidra |
|
|
J0202 |
|
Lemtrada |
alemtuzumab |
|
J3391 |
|
Lenmeldy |
atidarsagene autotemcel |
|
J0174 |
|
Leqembi |
lecanemab-irmb |
|
J1306 |
|
Leqvio |
inclisiran |
|
J1954 |
|
Leuprolide Acetate Depot |
leuprolide acetate (for depot suspension) (cipla) |
|
J9119 |
|
Libtayo |
cemiplimab-rwlc |
|
J1818 |
|
Loargys |
pegzilarginase-nbln |
|
J3263 |
|
Loqtorzi |
toripalimab-tpzi |
|
J2778 |
|
Lucentis |
ranibizumab |
|
J0220 |
|
Lumizyme |
alglucosidase alfa |
|
J0221 |
|
Lumizyme |
alglucosidase alfa |
|
J9350 |
|
Lunsumio Velo |
mosunetuzumab-axgb |
|
J1950 |
|
Lupron Depot |
leuprolide acetate (for depot suspension) |
|
J9217 |
|
Lupron Depot |
leuprolide acetate (for depot suspension) |
|
J1950 |
|
Lupron Depot Ped |
leuprolide acetate (for depot suspension) |
|
A9513 |
|
Lutathera |
lutetium Lu 177 dotatate |
|
J3398 |
|
Luxturna |
voretigene neparvovec-rzyl |
|
J3394 |
|
Lyfgenia |
lovotibeglogene autotemcel |
|
J9161 |
|
Lymphir |
denileukin difitox-cxdl |
|
C9307 J9601 |
|
Lynozyfic |
linvoseltamab-gcpt |
|
J9353 |
|
Margenza |
margetuximab-cmkb |
|
J3397 |
|
Mepsevii |
vestronidase alfa-vjbk |
|
J0888 |
|
Mircera |
methoxy polyethylene glycol-epoetin beta (non-esrd) |
|
J9349 |
|
Monjuvi |
tafasitamab-cxix |
|
J1437 |
|
Monoferric |
ferric derisomaltose |
|
J7327 |
|
Monovisc |
hyaluronan or derivative |
|
Q5107 |
|
Mvasi |
bevacizumab-awwb |
|
J0587 |
|
Myobloc |
rimabotulinumtoxinb |
|
J1458 |
|
Naglazyme |
galsulfase |
|
J2506 |
|
Neulasta |
pegfilgrastim |
|
J0219 |
|
Nexviazyme |
avalglucosidase alfa-ngpt |
|
J9038 |
|
Niktimvo |
axatilimab-csfr |
|
J7182 |
|
Novoeight |
antihemophilic factor (recombinant) |
|
J7189 |
|
Novoseven RT |
coagulation factor viia (recombinant) |
|
J2802 |
|
Nplate |
romiplostim |
|
J2182 |
|
Nucala |
mepolizumab |
|
Q5148 |
|
Nypozi |
filgrastim-txid |
|
Q5122 |
|
Nyvepria |
pegfilgrastim-apgf |
|
J2350 |
|
Ocrevus |
ocrelizumab |
|
J2351 |
|
Ocrevus Zunovo |
ocrelizumab, hyaluronidase-ocsq |
|
J1568 |
|
Octagam |
intravenous immune globulin |
|
Q5114 |
|
Ogivri |
trastuzumab-dkst |
|
J3406 |
|
Omisirge |
omidubicel-onlv |
|
J2267 |
|
Omvoh IV |
mirikizumab-mrkz |
|
J9266 |
|
Oncaspar |
pegaspargase |
|
J9205 |
|
Onivyde |
irinotecan liposome |
|
J0222 |
|
Onpattro |
patisiran |
|
Q5112 |
|
Ontruzant |
trastuzumab-dttb |
|
J9299 |
|
Opdivo |
nivolumab |
|
J9289 |
|
Opdivo Qvantig |
nivolumab and hyaluronidase-nvhy |
|
J9298 |
|
Opdualag |
nivolumab/relatlimab-rmbw |
|
Q5153 |
|
Opuviz |
aflibercept-yszy |
|
J0129 |
|
Orencia IV |
abatacept |
|
Q5157 |
|
Osenvelt |
denosumab-bmwo |
|
Q5159 |
|
Ospomyv |
denosumab-dssb |
|
J0224 |
|
Oxlumo |
lumasiran |
|
Q5165 |
|
Oziltus |
denosumab-mobz |
|
J9264 |
|
paclitaxel albumin-bound (American Regent) |
paclitaxel albumin-bound |
|
J9177 |
|
Padcev |
enfortumab vedotin-ejfv |
|
J2468 |
|
Palonosetron |
palonosetron (Avyxa) |
|
J1576 |
|
Panzyga |
intravenous immune globulin |
|
J3404 |
|
Papzimeos |
zopapogene imadenovec-drba |
|
Q5147 |
|
Pavblu |
aflibercept-ayyh |
|
Q5127 |
|
Pegfilstrastim-fpgk |
Pegfilstrastim-fpgk |
|
S0148 |
|
Peg-Intron |
pegylated interferon alfa-2b |
|
J9304 |
|
Pemfexy |
pemetrexed |
|
J9324 |
|
Pemrydi RTU |
pemetrexed |
|
J9999/C9399 |
83654-0105-01 |
Penpulimab-kcqx |
penpulimab-kcqx |
|
J9306 |
|
Perjeta |
pertuzumab |
|
J9316 |
|
Phesgo |
Pertuzumab, trastuzumab, hyaluronidase-zzxf |
|
J1307 |
|
Piasky |
crovalimab-akkz |
|
A9607 |
|
Pluvicto |
lutetium Lu 177 vipivotide tetraxetan |
|
J9309 |
|
Polivy |
polatuzumab vedotin-piiq |
|
J1203 |
|
Pombiliti |
cipaglucosidase alfa-atga |
| Q5173 |
|
Ponlimsi |
denosumab-adet |
|
J9204 |
|
Poteligeo |
mogamulizumab-kpkc |
|
J1459 |
|
Privigen |
intravenous immune globulin |
|
J0885 |
|
Procrit/Epogen |
epoetin alfa |
|
J7194 |
|
Profilnine |
factor ix complex |
|
J0256 |
|
Prolastin-C |
alpha-1-proteinase inhibitor |
|
J9015 |
|
Proleukin |
aldesleukin |
|
J0897 |
|
Prolia |
denosumab |
|
Q2043 |
|
Provenge |
sipuleucel-t |
|
|
|
Pyzchiva IV Only |
ustekinumab-ttwe |
|
J1304 |
|
Qalsody |
tofersen |
|
J7174 |
|
Qfitlia |
Hemophilia A |
| J1577 |
|
Qivigy |
intravenous immune globulin |
|
J1301 |
|
Radicava |
edaravone |
|
J7203 |
|
Rebinyn |
coagulation factor IX (recombinant), GlycoPEGylated |
|
J0896 |
|
Reblozyl |
luspatercept-aamt |
|
J7192 |
|
Recombinate |
antihemophilic factor (recombinant) |
|
J1745 |
|
Remicade |
infliximab |
|
Q5104 |
|
Renflexis |
infliximab-abda |
|
Q5106 |
|
Retacrit |
epoetin alfa-epbx |
|
J3590/C9399 |
10122-0502-01 |
Revcovi |
elapeademase-lvlr |
|
Q5123 |
|
Riabni |
rituximab-arrx |
|
J9312 |
|
Rituxan |
rituximab |
|
J9311 |
|
Rituxan Hycela |
rituximab and hyaluronidase human |
|
J3490/C9399 |
00169-5308-01 |
Rivfloza |
nedosiran |
|
J7200 |
|
Rixubis |
coagulation factor ix (recombinant) |
|
J1412 |
|
Roctavian |
valoctocogene Roxaparvovec-rvox |
|
J1449 |
|
Rolvedon |
eflapegrastim-xnst |
|
J9318 |
|
romidepsin |
romidepsin |
|
J0596 |
|
Ruconest |
c1 esterase inhibitor [recombinant] |
|
Q5119 |
|
Ruxience |
rituximab-pvvr |
|
J9061 |
|
Rybrevant |
amivantamab-vmjw |
|
J9062 |
|
Rybrevant Faspro |
amivantamab and hyaluronisase-lpuj |
|
J9021 |
|
Rylaze |
asparaginase erwinia chrysanthemi (recombinant)-rywn |
|
J3590/C9399 |
73648-0154-01 |
Ryoncil |
remestemcel-L-rknd |
|
J3402 |
|
Ryoncil |
remestemcel-L-rknd |
|
J2998 |
|
Ryplazim |
plasminogen, human-tvmh |
|
J9333 |
|
Rystiggo |
rozanolixizumab-noli |
|
J0870 |
|
Rytelo |
imetelstat |
|
J9361 |
|
Ryzneuta |
efbemalenograstim alfa-vuxw |
|
J2353 |
|
Sandostatin_LAR |
octreotide depot |
|
J0491 |
|
Saphnelo |
anifrolumab-fnia |
|
J9227 |
|
Sarclisa |
isatuximab-irfc |
|
Q9998 |
|
Selarsdi / IV |
ustekinumab-aekn |
|
J7212 |
|
Sevenfact |
coagulation factor viia (recombinant) |
|
J1602 |
|
Simponi_ARIA |
golimumab |
|
J2327 |
|
Skyrizi IV |
risankizumab-rzaa |
|
J3387 |
|
Skysona |
elivaldogene autotemcel |
|
J1299 |
|
Soliris |
eculizumab |
|
J1747 |
|
Spevigo IV |
spesolimab |
|
J2326 |
|
Spinraza |
nusinersen |
|
J0013 |
|
Spravato |
esketamine |
|
Q5164 |
|
Starjemza IV and SQ |
ustekinumab-hmny |
|
J3358 |
|
Stelara IV |
ustekinumab |
|
Q5099 |
|
Steqeyma IV Only |
ustekinumab-stba |
|
Q5127 |
|
Stimufend |
pegfilgrastim-fpgk |
|
Q5157 |
|
Stoboclo |
denosumab-bmwo |
|
J7321 |
|
Supartz |
hyaluronan or derivative |
|
J9226 |
|
Supprelin LA |
histrelin acetate subcutaneous implant |
|
J1627 |
|
Sustol |
granisetron extended-release |
|
J2779 |
|
Susvimo |
ranibizumab |
|
J2781 |
|
Syfovre |
pegcetacoplan |
|
90378 |
|
Synagis |
palivizumab |
|
J7331 |
|
Synojoynt |
hyaluronan or derivative |
|
J0593 |
|
Takhzyro |
lanadelumab-flyo |
|
J3055 |
|
Talvey |
talquetamab-tgvs |
|
Q2053 |
|
Tecartus |
brexucabtagene autoleucel |
|
Q2057 |
|
Tecelra |
afamitresgene autoleucel |
|
J9022 |
|
Tecentriq |
atezolizumab |
|
J9024 |
|
Tecentriq Hybreza |
atelizomab, hyaluronidase-tqjs |
|
J9380 |
|
Tecvayli |
teclistamab-cqyv |
|
J3241 |
|
Tepezza |
teprotumumab-trbw |
|
J1073 |
|
Testopel |
testosterone pellets |
|
J9329 |
|
Tevimbra |
tislelizumab-jsgr |
|
J2356 |
|
Tezspire |
tezepelumab-ekko |
|
J9273 |
|
Tivdak |
tisotumab vedotin-tftv |
|
Q5135 |
On with another code |
Tocilizumab-aazg IV only |
tocilizumab-aazg |
|
J3590/C9399 |
72606-0048-01 |
Tocilizumab-anoh IV Only |
Tocilizumab-anoh |
|
Q5133 |
|
Tofidence |
tocilizumab-bavi |
|
Q5113 |
On with another code |
Trastuzumab-pkrb |
trastuzumab-pkrb |
|
Q5116 |
|
Trazimera |
trastuzumab-qyyp |
|
J9033 |
|
Treanda |
bendamustine |
|
J3315 |
|
Trelstar |
triptorelin pamoate |
|
J1628 |
|
Tremfya IV |
guselkumab |
|
J7332 |
|
Triluron |
Sodium Hyaluronate |
|
J3316 |
|
Triptodur |
triptorelin extended-release |
|
J7329 |
|
TriVisc |
hyaluronan or derivative |
|
J9317 |
|
Trodelvy |
sacituzumab govitecan-hziy |
|
Q5115 |
|
Truxima |
rituximab-abbs |
|
Q5135 Q2038 |
|
Tyenne IV Only |
tocilizumab-aazg |
|
Q5134 |
|
Tyruko |
natalizumab-sztn |
|
J2323 |
|
Tysabri |
natalizumab |
|
J9381 |
|
Tzield |
teplizumab-mzwv |
|
Q5111 |
|
Udenyca |
pegfilgrastim-jmdb |
|
J1303 |
|
Ultomiris |
ravulizumab-cwvz |
|
J9275 |
|
Unloxcyt |
cosibelimab-ipdl |
|
J1823 |
|
Uplizna |
inebilizumab-cdon |
|
J3358 |
On with another code |
Ustekinumab IV only |
ustekinumab |
|
Q9999 |
On with another code |
Ustekinumab-aauz IV only |
ustekinumab-aauz |
|
Q9998 |
|
Ustekinumab-aekn IV |
ustekinumab-aekn |
|
Q5099 |
On with another code |
Ustekinumab-stba IV only |
ustekinumab-stba |
|
J9217 |
|
Vabrinty |
leuprolide acetate (for depot supsension) |
|
J2777 |
|
Vabysmo |
faricimab-svoa |
|
J9303 |
|
Vectibix |
panitumumab |
|
Q5129 |
|
Vegzelma |
bevacizumab-adcd |
|
J9376 |
|
Veopoz |
pozelimab-bbfg |
|
J1427 |
|
Viltepso |
viltolarsen |
|
J1322 |
|
Vimizim |
elosulfase alfa |
|
J7321 |
|
Visco-3 |
hyaluronan or derivative |
|
J9056 |
|
Vivimusta |
bendamustine |
|
J7179 |
|
Vonvendi |
von willebrand factor (recombinant) |
|
J3385 |
|
Vpriv |
velaglucerase alfa |
|
J3032 |
|
Vyepti |
eptinezumab-jjmr |
|
J3401 |
|
Vyjuvek |
beremagene geperpavec-svdt |
|
J1326 |
|
Vyloy |
zolbetuximab-clzb |
|
J1429 |
|
Vyondys-53 |
golodirsen |
|
J9332 |
|
Vyvgart |
efgartigimod alfa-fcab |
|
J9334 |
|
Vyvgart Hytrulo |
efgartigimod alfa hyaluronidase-qvfc |
|
C9311 |
|
Wainua |
eplontersen |
|
Q5138 |
|
Wezlana IV |
ustekinumab-auub |
|
J7183 |
|
Wilate |
von willebrand factor/coagulation factor viii complex |
|
Q5136 |
|
Wyost |
denosumab-bbdz |
|
Q5159 |
|
Xbryk |
denosumab-dssb |
|
J1558 |
|
Xembify |
subcutaneous immune globulin |
|
J0218 |
|
Xenpozyme |
olipidase alfa |
|
J0588 |
|
Xeomin |
incobotulinumtoxina |
|
J0897 |
|
Xgeva |
denosumab |
|
A9606 |
|
Xofigo |
radium-223 dichloride |
|
J2357 |
|
Xolair |
omalizumab |
| Q5167 |
|
Xtrenbo |
denosumab-qbde |
|
J7185 |
|
Xyntha |
antihemophilic factor (recombinant) |
|
J9228 |
|
Yervoy |
ipilimumab |
|
Q5155 |
|
Yesafili |
aflibercept-jbvfv |
|
Q2041 |
|
Yescarta |
axicabtagene ciloleucel |
|
Q5100 |
|
Yesintek IV Only |
ustekinumab-kfce |
|
J1553 |
|
Yimmugo |
intravenous immune globulin |
|
J9352/J9362 |
|
Yondelis |
trabectedin |
|
J9400 |
|
Zaltrap |
ziv-aflibercept |
|
J0256 |
|
Zemaira |
alpha-1-proteinase inhibitor |
|
J9223 |
|
Zepzelca |
lurbinectedin |
|
A9543 |
|
Zevalin |
ibritumomab tiuxetan |
|
Q5120 |
|
Ziextenzo |
pegfilgrastim-bmez |
|
J9276 |
|
Ziihera |
zandatamab-hrii |
|
J3304 |
|
Zilretta |
triamcinolone acetonide |
|
Q5118 |
|
Zirabev |
bevacizumab-bvzr |
|
J9202 |
|
Zoladex |
goserelin acetate implant |
|
J3399 |
|
Zolgensma |
onasemnogene abeparvovac-xioi |
|
J9282 |
|
Zusduri |
mitomycin |
|
J9359 |
|
Zynlonta |
loncastuximab tesirine-lpyl |
|
J3393 |
|
Zynteglo |
betibeglogene autotemcel |
|
J9345 |
|
Zynyz |
retifanlimab-dlwr |
|
|
|
|
|
Quick Code Search
Procedure
Diagnosis
Codes
Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each
Lutetium lu 177, dotatate, therapeutic, 1 millicurie
Iodine i-131 sodium iodide capsule(s), therapeutic, per millicurie
Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries
Iodine i-131, iobenguane, 1 millicurie
Radium ra-223 dichloride, therapeutic, per microcurie
Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie
Injection, datopotamab deruxtecan-dlnk, 1 mg
Injection, linvoseltamab-gcpt, 1 mg
Injection, carboplatin (avyxa), 1 mg
Injection, eplontersen, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
Injection, trabectedin (apotex), not therapeutically equivalent to j9362, 0.01 mg
Injection, pivekimab sunirine-pvzy, 0.01 mg
Unclassified drugs or biologicals
Esketamine, nasal spray, 1 mg
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 is self administered)
Injection, lecanemab-irmb, 1 mg
Injection, donanemab-azbt, 2 mg
Injection, aflibercept hd, 1 mg
Injection, aflibercept, 1 mg
Injection, brolucizumab-dbll, 1 mg
Injection, agalsidase beta, 1 mg
Injection, alemtuzumab, 1 mg
Injection, alglucerase, per 10 units
Injection, alefacept, 0.5 mg
Injection, velmanase alfa-tycv, 1 mg
Injection, olipudase alfa-rpcp, 1 mg
Injection, avalglucosidase alfa-ngpt, 4 mg
Injection, alglucosidase alfa, 10 mg, not otherwise specified
Injection, alglucosidase alfa, (lumizyme), 10 mg
Injection, Patisiran, 0.1 mg
Injection, givosiran, 0.5 mg
Injection, lumasiran, 0.5 mg
Injection, vutrisiran, 1 mg
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg
Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg
Injection, belimumab, 10 mg
Injection, anifrolumab-fnia, 1 mg
Injection, benralizumab, 1 mg
Injection, cerliponase alfa, 1 mg
Injection, burosumab-twza 1 mg
Injection, onabotulinumtoxina, 1 unit
Injection, abobotulinumtoxina, 5 units
Injection, rimabotulinumtoxinb, 100 units
Injection, incobotulinumtoxin a, 1 unit
Injection, daxibotulinumtoxina-lanm, 1 unit
Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)
Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units
Injection, c-1 esterase inhibitor (human), berinert, 10 units
Injection, c-1 esterase inhibitor (human), cinryze, 10 units
Injection, c-1 esterase inhibitor (human), (haegarda), 10 units
Injection, canakinumab, 1 mg
Injection, levoleucovorin, not otherwise specified, 0.5 mg
Injection, levoleucovorin (khapzory), 0.5 mg
Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
Injection, crizanlizumab-tmca, 5 mg
Injection, corticotropin (acthar gel), up to 40 units
Injection, corticotropin (ani), up to 40 units
Injection, imetelstat, 1 mg
Injection, darbepoetin alfa, 1 microgram (non-esrd use)
Injection, epoetin alfa, (for non-esrd use), 1000 units
Injection, epoetin beta, 1 microgram, (for non esrd use)
Injection, luspatercept-aamt, 0.25 mg
Injection, denosumab, 1 mg
Testosterone pellet, implant, 75 mg
Injection, cipaglucosidase alfa-atga, 5 mg
Injection, narsoplimab-wuug, 1 mg
Injection, ecallantide, 1 mg
Injection, eculizumab, 2 mg
Injection, edaravone, 1 mg
Injection, sutimlimab-jome, 10 mg
Injection, ravulizumab-cwvz, 10 mg
Injection, tofersen, 1 mg
Injection, evinacumab-dgnb, 5mg
Injection, inclisiran, 1 mg
Injection, crovalimab-akkz, 10 mg
Injection, elosulfase alfa, 1 mg
Injection, elranatamab-bcmm, 1 mg
Injection, zolbetuximab-clzb, 2 mg
Injection, etranacogene dezaparvovec-drlb, per therapeutic dose
Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes
Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose
Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose
Injection, casimersen, 10 mg
Injection, viltolarsen, 10 mg
Injection, eteplirsen, 10 mg
Injection, golodirsen, 10 mg
Injection, ferric derisomaltose, 10 mg
Injection, ferric carboxymaltose, 1 mg
Injection, trilaciclib, 1mg
Injection, eflapegrastim-xnst, 0.1 mg
Injection, fosnetupitant 235 mg and palonosetron 0.25 mg
Injection, galsulfase, 1 mg
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg
Injection, immune globulin (cutaquig), 100 mg
Injection, immune globulin (alyglo), 500 mg
Injection, immune globulin (yimmugo), 100 mg
Injection, immune globulin (asceniv), 500 mg
Injection, immune globulin (cuvitru), 100 mg
Injection, immune globulin (bivigam), 500 mg
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg
Injection, immune globulin (xembify), 100 mg
Injection, immune globulin (hizentra), 100 mg
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 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, non-lyophilized (e.g. liquid), 500 mg
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin
Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg
Injection, immune globulin (qivigy), 100 mg
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg
Injection, golimumab, 1 mg, for intravenous use
Injection, granisetron, extended-release, 0.1 mg
Injection, guselkumab, 1 mg
Injection, idursulfase, 1 mg
Injection, icatibant, 1 mg
Injection infliximab, 10 mg
Injection, spesolimab-sbzo, 1 mg
Injection, tividenofusp alfa-eknm, 1 mg
Injection, imiglucerase, 10 units
Injection, pegzilarginase-nbln, 0.05 mg
Injection, inebilizumab-cdon, 1 mg
Injection, laronidase, 0.1 mg
Injection, leuprolide acetate (for depot suspension), per 3.75 mg
Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg
Leuprolide injectable, camcevi, 1 mg
Injection, leuprolide acetate for depot suspension (cipla), 7.5 mg
Injection, mepolizumab, 1 mg
Injection, mirikizumab-mrkz, 1 mg
Injection, natalizumab, 1 mg
Injection, nusinersen, 0.1 mg
Injection, risankizumab-rzaa, intravenous, 1 mg
Injection, ublituximab-xiiy, 1mg
Injection, ocrelizumab, 1 mg
Injection, ocrelizumab, 1 mg and hyaluronidase-ocsq
Injection, octreotide, depot form for intramuscular injection, 1 mg
Injection, tezepelumab-ekko, 1 mg
Injection, omalizumab, 5 mg
Injection, depemokimab-ulaa, 1 mg
Injection, palonosetron hydrochloride (avyxa), not therapeutically equivalent to j2469, 25 micrograms
Injection, pegfilgrastim, excludes biosimilar, 0.5 mg
Injection, pegloticase, 1 mg
Injection, pegunigalsidase alfa-iwxj, 1 mg
Injection, faricimab-svoa, 0.1 mg
Injection, ranibizumab, 0.1 mg
Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg
Injection, pegcetacoplan, intravitreal, 1 mg
Injection, avacincaptad pegol, 0.1 mg
Injection, reslizumab, 1 mg
Injection, rilonacept, 1 mg
Injection, romiplostim, 1 microgram
Injection, sebelipase alfa, 1 mg
Injection, plasminogen, human-tvmh, 1 mg
Injection, eptinezumab-jjmr, 1 mg
Injection, talquetamab-tgvs, 0.25 mg
Injection, taliglucerace alfa, 10 units
Injection, romosozumab-aqqg, 1 mg
Injection, teprotumumab-trbw, 10 mg
Injection, tildrakizumab, 1 mg
Injection, secukinumab, intravenous, 1 mg
Injection, tocilizumab, 1 mg
Injection, toripalimab-tpzi, 1 mg
Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg
Injection, triptorelin pamoate, 3.75 mg
Injection, triptorelin, extended-release, 3.75 mg
Ustekinumab, for intravenous injection, 1 mg
Injection, vedolizumab, 1 mg
Injection, velaglucerase alfa, 100 units
Injection, elivaldogene autotemcel, per treatment
Injection, atidarsagene autotemcel, per treatment
Injection, exagamglogene autotemcel, per treatment
Injection, betibeglogene autotemcel, per treatment
Injection, lovotibeglogene autotemcel, per treatment
Injection, vestronidase alfa-vjbk, 1 mg
Injection, voretigene neparvovec-rzyl, 1 billion vector genomes
Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes
Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml
Injection, remestemcel-l-rknd, per therapeutic dose
Revakinagene taroretcel-lwey, per implant
Injection, onasemnogene abeparvovec-brve, per treatment
Injection, omidubicel-onlv, per therapeutic dose
Unclassified drugs
Unclassified biologics
Injection, emicizumab-kxwh, 0.5 mg
Injection, adamts13, recombinant-krhn, 10 iu
Injection, marstacimab-hncq, 0.5 mg
Injection, concizumab-mtci, 0.5 mg
Injection, fitusiran, 0.04 mg
Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u.
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u.
Injection, von willebrand factor complex (humate-p), per iu vwf:rco
Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram
Factor viii (antihemophilic factor, human) per i.u.
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u.
Factor ix, complex, per i.u.
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu
Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u.
Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu
Injection, factor viii fc fusion protein (recombinant), per iu
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u.
Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.
Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u.
Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u.
Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram
Injection, coagulation factor ix (recombinant), ixinity, 1 i.u.
Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii i.u.
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg
Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose
Hyaluronan or derivative, gel-syn, for intra-articular injection, 0.1 mg
Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg
Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg
Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg
Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg
Leuprolide injectable (camcevi etm), 1 mg
Injection, datopotamab deruxtecan-dlnk, 1 mg
Injection, aldesleukin, per single use vial
Injection, asparaginase, recombinant, (rylaze), 0.1 mg
Injection, atezolizumab, 10 mg
Injection, avelumab, 10 mg
Injection, atezolizumab, 5 mg and hyaluronidase-tqjs
Injection, tarlatamab-dlle, 1 mg
Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram
Injection, nadofaragene firadenovec-vncg, per therapeutic dose
Injection, bendamustine hcl (treanda), 1 mg
Injection, bendamustine hcl (bendeka), 1 mg
Injection, bevacizumab, 10 mg
Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mg
Injection, axatilimab-csfr, 0.1 mg
Injection, blinatumomab, 1 microgram
Injection, brentuximab vedotin, 1 mg
Injection, cabazitaxel, 1 mg
Injection, carfilzomib, 1 mg
Injection, belantamab mafodotin-blmf, 0.1 mg
Injection, cetuximab, 10 mg
Injection, bendamustine hydrochloride (vivimusta), 1 mg
Injection, amivantamab-vmjw, 2 mg
Injection, amivantamab 5 mg and hyaluronidase-lpuj
Injection, mirvetuximab soravtansine-gynx, 1 mg
Injection, cabazitaxel (sandoz), not therapeutically equivalent to j9043, 1 mg
Injection, bendamustine hydrochloride (avyxa), 1 mg
Injection, cemiplimab-rwlc, 1 mg
Injection, daratumumab, 10 mg and hyaluronidase-fihj
Injection, daratumumab, 10 mg
Injection, degarelix, 1 mg
Injection, denileukin diftitox-cxdl, 1 mcg
Injection, durvalumab, 10 mg
Injection, enfortumab vedotin-ejfv, 0.25 mg
Injection, eribulin mesylate, 0.1 mg
Gemcitabine intravesical system, 225 mg
Injection, gemcitabine hydrochloride (avyxa), 200 mg
Injection, gemcitabine hydrochloride, (infugem), 100 mg
Goserelin acetate implant, per 3.6 mg
Injection, mogamulizumab-kpkc, 1 mg
Injection, irinotecan liposome, 1 mg
Injection, emapalumab-lzsg, 1 mg
Injection, interferon, gamma 1-b, 3 million units
Leuprolide acetate (for depot suspension), 7.5 mg
Injection, lurbinectedin, 0.1 mg
Histrelin implant (supprelin la), 50 mg
Injection, isatuximab-irfc, 10 mg
Injection, ipilimumab, 1 mg
Injection, melphalan (evomela), 1 mg
Injection, nipocalimab-aahu, 3 mg
Injection, paclitaxel protein-bound particles, 1 mg
Injection, pegaspargase, per single dose vial
Injection, tagraxofusp-erzs, 10 micrograms
Injection, pembrolizumab, 1 mg
Injection, dostarlimab-gxly, 10 mg
Injection, tisotumab vedotin-tftv, 1 mg
Injection, tebentafusp-tebn, 1 microgram
Injection, cosibelimab-ipdl, 2 mg
Injection, zanidatamab-hrii, 2 mg
Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph
Injection, carboplatin (avyxa), 1 mg
Mitomycin pyelocalyceal instillation, 1 mg
Mitomycin, intravesical instillation, 1 mg
Injection, glofitamab-gxbm, 2.5 mg
Injection, nivolumab, 2 mg and hyaluronidase-nvhy
Injection, pemetrexed (avyxa), not therapeutically equivalent to j9305, 10 mg
Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg
Injection, nivolumab, 1 mg
Injection, obinutuzumab, 10 mg
Injection, panitumumab, 10 mg
Injection, pemetrexed (pemfexy), 10 mg
Injection, pertuzumab, 1 mg
Injection, ramucirumab, 5 mg
Injection, polatuzumab vedotin-piiq, 1 mg
Injection, rituximab 10 mg and hyaluronidase
Injection, rituximab, 10 mg
Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg
Injection, sacituzumab govitecan-hziy, 2.5 mg
Injection, romidepsin, non-lyophilized, 0.1 mg
Injection, romidepsin, lyophilized, 0.1 mg
Injection, epcoritamab-bysp, 0.16 mg
Injection, pemetrexed (pemrydi rtu), 10 mg
Injection, telisotuzumab vedotin-tllv, 1 mg
Injection, tislelizumab-jsgr, 1mg
Injection, sirolimus protein-bound particles, 1 mg
Injection, efgartigimod alfa-fcab, 2mg
Injection, rozanolixizumab-noli, 1 mg
Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc
Injection, retifanlimab-dlwr, 1 mg
Injection, tremelimumab-actl, 1 mg
Injection, naxitamab-gqgk, 1 mg
Injection, tafasitamab-cxix, 2 mg
Injection, mosunetuzumab-axgb, 1 mg
Injection, trabectedin, 0.1 mg
Injection, margetuximab-cmkb, 5 mg
Injection, ado-trastuzumab emtansine, 1 mg
Injection, trastuzumab, 10 mg
Injection, trastuzumab, 10 mg and Hyaluronidase-oysk
Injection, fam-trastuzumab deruxtecan-nxki, 1 mg
Injection, loncastuximab tesirine-lpyl, 0.075 mg
Injection, efbemalenograstim alfa-vuxw, 0.5 mg
Injection, trabectedin, 0.01 mg
Injection, pozelimab-bbfg, 1 mg
Injection, teclistamab-cqyv, 0.5 mg
Injection, teplizumab-mzwv, 5 mcg
Injection, zenocutuzumab-zbco, 1 mg
Injection, ziv-aflibercept, 1 mg
Injection, linvoseltamab-gcpt, 1 mg
Not otherwise classified, antineoplastic drugs
Injection, tocilizumab-aazg, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, 1 mg
Axicabtagene Ciloleucel, up to 200 Million Autologous Anti-CD19 CAR T Cells, Including Leukapheresis And Dose Preparation Procedures, Per Infusion
Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion
Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Idecabtagene vicleucel, up to 460 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose
Obecabtagene autoleucel, 10 up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion
Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg
Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg
Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg
Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
Injection, infliximab-abda, biosimilar, (renflexis), 10 mg
Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units
Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg
Injection, pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg
Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg
Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mgÂ
Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg
Inj rituximab-abbs bio 10 mg
Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg
Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg
Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg
Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg
Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg
Injection, infliximab-axxq, biosimilar, (avsola), 10 mg
Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg
Injection, rituximab-arrx, biosimilar, (riabni), 10 mg
Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg
Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg
Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg
Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg
Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg
Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg
Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mg
Injection, natalizumab-sztn (tyruko), biosimilar, 1 mg
Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg
Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg
Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg
Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg
Injection, aflibercept-ayyh (pavblu), biosimilar, 1 mg
Injection, filgrastim-txid (nypozi), biosimilar, 1 microgram
Injection, aflibercept-abzv (enzeevu), biosimilar, 1 mg
Injection, aflibercept-mrbb (ahzantive), biosimilar, 1 mg
Injection, eculizumab-aagh (epysqli), biosimilar, 2 mg
Injection, eculizumab-aeeb (bkemv), biosimilar, 2 mg
Injection, aflibercept-yszy (opuviz), biosimilar, 1 mg
Injection, aflibercept-jbvf (yesafili), biosimilar, 1 mg
Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg
Injection, denosumab-bmwo (stoboclo/osenvelt), biosimilar, 1 mg
Injection, denosumab-bnht (bomyntra/conexxence), biosimilar, 1 mg
Injection, denosumab-dssb (ospomyv/xbryk), biosimilar, 1 mg
Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg
Injection, denosumab-kyqq (aukelso/bosaya), biosimilar, 1 mg
Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg
Injection, ustekinumab-hmny (starjemza), biosimilar, 1 mg
Injection, denosumab-mobz (oziltus), biosimilar, 1 mg
Injection, denosumab-desu (osvyrti/jubereq), biosimilar, 1 mg
Injection, denosumab-qbde (enoby/xtrenbo), biosimilar, 1 mg
Injection, pegfilgrastim-unne (armlupeg), biosimilar, 0.5 mg
Injection, aflibercept-boav (eydenzelt), biosimilar, 1 mg
Injection, denosumab-mobz (boncresa), biosimilar, 1 mg
Injection, denosumab-adet (ponlimsi), biosimilar, 1 mg
Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg
Injection, ustekinumab-aekn (selarsdi), 1 mg
Injection, ustekinumab-aauz (otulfi), biosimilar, 1 mg
Injection, pegylated interferon alfa-2b, 10 mcg
Revisions
|
10-13-2026
Removed J0185 as this code does not require a PA and is on a post claim review. |
|
09-09-2026
Added codes effective 10/01/2026 C9311 C9312 C9313 J1757 J1818 J3406 J9066 J9362 Q5173 |
|
07-15-2026
Added Kresladi to policy effective 07/15/2026 |
|
06-26-2026
Added new hcpcs codes effective 07/01/2026 Q5169 J9053 Q5171 J2361 J3405 Q5166 J9350 Q5165 J9062 J1289 AND Loargys and Ponlimsi |
|
06-10-2026
REMOVED J8502 FROM POLICY |
|
05-15-2026
Removing J2469 from this policy and the PA list and will be reviewed retrospectively and added C9399/J3590 Lantidra effective 06/01/2026 |
|
03-27-2026
Added new codes for 04/01/2026: J1553 J3404 J8502 J9003 J9183 J9277 J9278 J9601 Q5161 Q5162 Q0238 |
|
02-15-2026
Adding the following drugs to the policy: Aukelso, Bilprevda, Bildyos, Bosaya, Enoby, Eydenzelt, Inlexzo, Keytruda Qlex, Kyxata, Lynozyfic, Papzimeos, Qivigy, Vabrinty, Xtrenbo. Also added codes C9307 & C9308 effective 2/15/2026. |
|
02-01-2026
Adding J7504 effective 2/1/2026 |
|
01-05-2026
Removed J9999 and NDC 61755-0054-01 and 61755-0056-01 for Lynozyfic as this was replaced by C9307. |
|
01-01-2026
Effective 1/1/2026: removed termed codes C9305, C9306 S0013 & S0189. Added codes J0013, J1073, J3387, J3389, J9184, J9256, J9282, J9326 & Q5160. |
|
10-30-2025
Versioned 10/1 due to new codes effective on 10/1/2025. |
