Pharmacy J-Codes Prior Authorization List - ConnectiCare [PDF]

PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY Last update: February 2019 Background: HCPCS codes (J-codes) can be administered through a member’s medical or pharmacy benefit. A few important notes: • If administered through the Pharmacy benefit, the drug must be obtained through Accredo Specialty Pharmacy unless the drug is a “limited distribution” drug and then the pharmacy through whom it can be obtained is noted below. • If the code you are looking for is not found on this list, please search by drug name (brand name) here AND on the Pharmacy Prior Authorization list found on https://main.myconnecticare.com/~/media/files/pharmacycentral/formularypalists.pdf?la=en • J3490, J3590 and J9999 are miscellaneous codes assigned to drugs that do not have a unique code assigned. Please search by drug brand name. • This list is subject to change on a routine basis.

* Please note, the list is sorted by Drug Name. To see if a specific drug is on this list, click on a letter and browse the table alphabetically.

A•B•C•D•E•F•G•H•I•J•K•L•M•N•O•P•Q•R•S•T•V•X•Y•Z Or, click on this

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DRUG NAME (BRAND/GENERIC)

LIMITED DISTRIBUTION PHARMACIES

J3262

Actemra (tocilizumab)

C9497

Adasuve (loxapine)

J9042

Adcetris (brentuximab vedotin) Seagen Secure

J7192

Advate (antihemophilic factor)

J7199, J7210

Afstyla (Hemophilia clotting factor)

J1454

Akynzeo (fosnetupitant/palonosetron)

J1931

Aldurazyme (laronidase)

J7186

Alphanate (Factor VIII/VWF)

J7193

AlphaNine SD (Factor IX)

J9305

Alimta (pemetrexed)

J9057

Aliqopa (Copanlisib) Back to Top Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | Page 1 of 12 http://www.connecticare.com/providers/commercial/pharmacypolicy.aspx

PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J7201

Alprolix (Factor IX)

J7198

Anti-inhibitor (Feiba VH)

J0364

Apokyn (apomorphine)

J0256

Aralast (Alpha-1 proteinase inhibitor)

J2793

Arcalyst (rilonacept)

J9302

Arzerra (ofatumumab)

J9035

Avastin (bevacizumab)

J3145

Aveed (testosterone undecanoate)

C9407

Azedra (iodine i-131 iobenguane)

J9023

Bavencio (avelumab)

J3490/C9462

Baxdela (delafloxacin)

J7194

Bebulin (Factor IX Complex)

J9034

Bendeka (bendamustine)

J7195

BeneFIX (Factor IX recombinant)

J0490

Benlysta (belimumab)

J0597

Berinert (C1 esterase inhibitor)

J9229

Besponsa (inotuzumab)

J1740

Boniva injection (ibandronate)

J9039

Blincyto (blinatumomab)

J0585

Botox (onaBotulinum toxin type A)

LIMITED DISTRIBUTION PHARMACIES

Acaria, CVS/ CareMark, Diplomat, Prime Therapeutics, iCore, Walgreen

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J0567

Brineura (Cerliponase Alfa)

J1786

Cerezyme (imiglucerase)

J0717

Cimzia (certolizumab)

J2786

Cinqair (reslizumab)

J0598

Cinryze (C1 esterase inhibitor)

J9027

Clolar (clofarabine)

Q9977

Compounded Drugs

J7180

Corifact (Factor XIII)

J0584

Crysvita (burosumab-twza)

J1555

Cuvitru (IVIG subcutaneous)

J9308

Cyramza (ramucirumab)

J0894

Dacogen (decitabine)

J9145

Darzalex (daratumumab)

J1095

Dexycu (dexamethasone)

Q2050

Doxil (doxorubicin, liposomal)

J7318

Durolane (hyaluronic acid)

J0586

Dysport (abobotulinumtoxinA)

J3490

Egrifta (tesamorelin)

J1743

Elaprase (idursulfase)

J7205

Eloctate (Factor VIII recombinant)

J9263

Eloxatin (oxaliplatin)

J3060

Elelyso (taliglucerase)

LIMITED DISTRIBUTION PHARMACIES

Professional Homecare

Biologics

CVS/CareMark, Prescription Solutions, , Right Source, Walgreen

Dohmen

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J3380

Entyvio (vedolizumab)

J9176

Empliciti (elotuzumab)

J9055

Erbitux (cetuximab)

J7323

Euflexxa (sodium hyauronate)

J1428

Exondys 51 (eteplirsen)

J0178

Eylea (Aflibercept Ophthalmic)

J0180

Fabrazyme (agalsidase beta)

J7190-J7192 Q9975

Factor VIII antihemophilic factor

J7194

Factor IX

J7180

Factor XIII

J0517

Fasenra

J1744

Firazyr (Icatibant Acetate)

J1325

Flolan (epoprostenol)

J9307

Folotyn (pralatrexate)

Q5108

Fulphila (pegfilgrastim)

J3490

Gattex (teduglutide)

J9301

Gazyva (obinutuzumab)

J7326

Gel-One (hyaluronic acid)

J7328

Gelsyn-3 (hyaluronic acid)

J0257

Glassia (Alpha-1-Proteinase Inhibitor–Human)

J7320

GenVisc (hyaluronic acid)

J1447

Granix (tbo-filgrastim)

C9015

Haegarda (C1 Inhibitor, Human)

LIMITED DISTRIBUTION PHARMACIES

Professional Homecare

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J9179

Halaven (eribulin)

J7192

Helixate (antihemophilic factor)

J7170

Hemlibra (Emicizumab-kxwh)

J7190

Hemofil M (antihemophilic factor)

J1571-IM formula J1573-IV formula

Hepagam B (Hepatitis B immune globulin)

J9355

Herceptin (trastuzumab)

J1559

Hizentra (IVIG)

J7187

Humate-P (Von Willebrand factor)

J7321

Hyalgan (sodium hyaluronate)

J7320

Hymovis (hyaluronic acid)

J1575

Hyqvia (IVIG subcutaneous)

J0638

Ilaris (canakinumab)

J3245

Ilumya (tildrakizumab-asmn)

J7313

Iluvien (fluocinolone acetonide intravitreal implant)

J9173

Imfinzi (Durvalumab)

J9325

Imlygic (talimogene)

Q5103

Inflectra (infliximab-dyyb)

J9214

Intron-A (interferon alfa 2B)

J3490

Iprivask (desirudin)

J9315

Istodax (romidepsin)

J1566

IVIG (Immune Globulin powder)

LIMITED DISTRIBUTION PHARMACIES

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J1556-Bivigam J1566-Carimune J0850-Cytogam J1572-Flebogamma J1569-Gammagard J1557-Gammaplex J1561-Gamunex J1568-Octagam J1599- Panzyga J1459-Privigen

IVIG (Immune Globulin liquid)

J9207

Ixempra (ixabepilone)

Q5109

Ixifi (infliximab-qbtx)

J7195

Ixinity (Factor IX recombinant)

J7316

Jetrea (ocriplasmin)

J9043

Jevtana (cabazitaxel)

C9399/J7199

Jivi (Antihemophilic Factor, Recombinant (Pegylated))

J9354

Kadcyla (ado-trastuzumab)

J1290

Kalbitor (ecallantide)

J2840

Kanuma (sebelipase alpha)

J9271

Keytruda (pembrolizumab)

J7192

Kogenate FS (antihemophilic factor)

J7211

Kovaltry (Factor VIII)

J2507

Krystexxa (pegloticase)

Q2042

Kymriah (Tisagenlecleucel)

J9047

Kyprolis (carfilzomib)

J9285

Lartruvo (olaratumab)

J0202

Lemtrada (alemtuzumab)

LIMITED DISTRIBUTION PHARMACIES

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J9999/C9399

Libtayo (cemiplimab-rwlc)

Q2049

Lipodox (doxorubicin liposomal)

J2778

Lucentis (ranibizumab Intravitreal)

J0221

Lumizyme (alglucosidase alfa)

J9999/C9399

Lumoxiti (Moxetumomab Pasudotox-tdfk)

A9513

Lutathera

J3398

Luxturna

J2503

Macugen (pegaptanib)

J9371

Marqibo (vincristine)

J3397

Mepsevii (vestronidase alfavjbk)

J7190

Monoclate P (antihemophilic factor)

J7193

Mononine (Factor IX (Human))

J7327

Monovisc (hyaluronic acid)

J2562

Mozobil (plerixaflor)

Q5107

Mvasi (bevacizumab-awwb)

J9203

Mylotarg (Gemtuzumab Ozogamicin)

J0587

Myobloc (botulinum toxin type B)

J0220

Myozyme (alglucosidase alfa)

J1458

Naglazyme (galsulfase)

Q5110

Nivestym (filgrastim)

J7182

Novoeight (antihemophilic factor)

LIMITED DISTRIBUTION PHARMACIES

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J7189

Novoseven (antihemophilic factor VIIa)

J2796

Nplate (romiplostim)

J2182

Nucala (mepolizumab)

J7209

Nuwiq (antihemophilic factor)

J2505

Neulasta (pegfilgrastim)

J1442

Neupogen (filgrastim)

J0485

Nulojix (belatacept)

J7188

Obizur (Antihemophilic Factor VIII)

J2350

Ocrevus (ocrelizumab)

J9205

Onivyde (Irinotecan Liposomal)

C9036/J3490

Onpattro (Patisiran)

J9299

Opdivo (nivolumab)

J0129

Orencia (abatacept)

J7324

Orthovisc (hyaluronan)

J3490

Otrexup (methotrexate)

J7312

Ozurdex (dexamethasone implant)

J9306

Perjeta (pertuzumab)

J9295

Portrazza (necitumumab)

C9038/J9999

Poteligeo (Mogamulizumabkpkc)

J2278

Prialt (ziconotide)

J0570

Probuphine Implant (buprenorphine)

LIMITED DISTRIBUTION PHARMACIES

Bioscrip

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

LIMITED DISTRIBUTION PHARMACIES

J7194

Profilnine/SD (Factor IX Complex)

J0256

Prolastin (alpha-1 proteinase inhibitor)

J9015

Proleukin (aldesleukin)

J0897

Prolia (denosumab)

Q2043

Provenge (sipuleucel-T)

Contact Manufacturer

J7336

Qutenza (capsaicin)

Contact Manufacturer

J1301

Radicava (edaravone)

J3490

Rasuvo (methotrexate)

J7203

Rebinyn (factor IX)

J7192

Recombinate (factor VIII antihemophilic factor)

J2212

Relistor (methylnaltrexone)

B4105

Relizorb (digestive enzymes)

J1745

Remicade (infliximab)

J3285

Remodulin (treprostinil)

Q5104

Renflexis (infliximab-abda)

J7311/C1821

Retisert (fluocinolone acetonide intravitreal implant)

J7178

RiaSTAP (fibrinogen concentrate)

J9312

Rituxan (rituximab)

J9311

Rituxan Hycela (rituximab/hyaluronidase)

J7200

Rixubis (Factor IX)

J0596

Ruconest (C1 Esterase Inhibitor (Recombinant)

Dohmen

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

LIMITED DISTRIBUTION PHARMACIES

J0604

Sensipar (cinacalcet)

Not Covered

J2502

Signifor (pasireotide)

J1602

Simponi ARIA (golimumab)

J1300

Soliris (ecuzliumab)

J1930

Somatuline Depot (lanreotide)

J2326

Spinraza (nusinersen)

J3357, J3358

Stelara (ustekinumab)

J7321

Supartz (hyaluronic acid)

J9226

Supprelin LA (histrelin implant)

J2860

Sylvant (siltuximab)

J3490

Synagis (palivizumab)

J9262

Synribo (omacetaxine)

J7325

Synvisc (3 injection series)

J7325

Synvisc One (1 injection)

C9399/J3590

Takhzyro (Lanadelumab-flyo Injection)

C9022

Tecentriq (atezolizumab)

J9328

Temodar Injection (temozolomide)

J9340

Tepadina (thiotepa)

J3490

Testopel (testosterone implant)

WALGREEN

J3240

Thyrogen (thyrotropin)

Thyrogen is a Pharmacy benefit

J9330

Torisel (temsirolimus)

J9033

Treanda (bendamustine)

Stelara is a pharmacy benefit

Diplomate

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

J1628

Tremfya (guselkumab)

J7181

Tretten (Coagulation Factor XIII)

J7329

TriVisc (hyaluronic Acid)

J1746

Trogarzo (Ibalizumab-uiyk)

J2323

Tysabri (natalizumab)

J7686

Tyvaso (treprostinil)

J9999, C9399

Unituxin (dinutuximab)

J9225

Vantas (histrelin implant)

J9303

Vectibix (panitumumab)

J9041/J9044

Velcade (bortezomib)

Q4074

Ventavis (iloprost)

J9025

Vidaza (azacitidine)

J1322

Vimizim (elosulfase alfa)

J7321

Visco-3 (sodium hyaluronate)

J7179

Vonvendi (Von Willebrand Factor)

J3385

Vpriv (velaglucerase alfa)

J9153

Vyxeos (daunorubicin/cytarabine)

J7183

Wilate (Factor VIII/VWF)

J0588

Xeomin (incobotulinumtoxinA)

J0775

Xiaflex (collagenase clostridium)

A9606

Xofigo (Radium Ra 223 Dichloride)

LIMITED DISTRIBUTION PHARMACIES

Nuclear Medicine and Hospital Clinics

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PHARMACY J-CODES PRIOR AUTHORIZATION LIST COMMERCIAL MEMBERS ONLY CODE

DRUG NAME (BRAND/GENERIC)

LIMITED DISTRIBUTION PHARMACIES

J2357

Xolair (omalizumab)

Xolair is a Pharmacy benefit

J9352

Yondelis (trabectedin)

J7185

Xyntha (antihemophilic factor)

J9228

Yervoy (ipilimumab)

Q2041

Yescarta (Axicabtagene Ciloleucel)

J9400

Zaltrap (ziv-aflibercept)

Q5101

Zarxio (filgrastim)

J0256

Zemaira (Alpha-1 proteinase inhibitor)

A9543

Zevalin (ibritumomab tiuxetan) Nuclear Medicine and Hospital Clinics

J3304

Zilretta (triamcinolone acetonide)

J0565

Zinplava (bezlotoxumab)

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