pharmacy j-codes prior authorization ist … · pharmacy j-codes prior authorization list...

PHARMACY J-CODES

PRIOR AUTHORIZATION LIST

COMMERCIAL MEMBERS ONLY

Last update: August 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 • U • V • W • X • Y • Z

Or, click on this Search button and enter the name of the drug in the pop-up task pane.

Code Drug Name (Brand/Generic)

Limited distribution Pharmacies

J9264 Abraxane (paclitaxel protein bound)

J3262 Actemra (tocilizumab)

J9216 Actimmune (interferon, gamma-1b)

C9497 Adasuve (loxapine)

J9042 Adcetris (brentuximab vedotin) Seagen Secure

J9000 Adriamycin (doxorubicin)

J9190 Adrucil/fluorouracil

J7192 Advate (antihemophilic factor)

J7207 Adynovate (factor VIII)

J7199, J7210 Afstyla (Hemophilia clotting factor)

J1454 Akynzeo (fosnetupitant/palonosetron)

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Pharmacy HCPCS Codes Prior Authorization List – Commercial Members Only | of 15

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PHARMACY J-CODES





J1931 Aldurazyme (laronidase)

J9215 Alferon (Interferon Alfa-N3)

J9305 Alimta (pemetrexed)

J9057 Aliqopa (Copanlisib)

J7186 Alphanate (Factor VIII/VWF)

J7193 AlphaNine SD (Factor IX)

J7201 Alprolix (Factor IX)

J7198 Anti-inhibitor (Feiba VH)

J0364 Apokyn (apomorphine)

J0256 Aralast (Alpha-1 proteinase inhibitor)

J2793 Arcalyst (rilonacept)

J9261 Arranon (nelarabine)

J9017 Arsenic Trioxide /Trisenox

J9302 Arzerra (ofatumumab)

J9035 Avastin (bevacizumab)

J3145 Aveed (testosterone undecanoate)

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

C9407 Azedra (iodine i-131 iobenguane)

J9023 Bavencio (avelumab)

J3490/C9462 Baxdela (delafloxacin)

J7194 Bebulin (Factor IX Complex)

J9032 Beleodaq (belinostat)

J9036 Belrapzo (bendamustine hydrochloride)

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PHARMACY J-CODES





J9034 Bendeka (bendamustine)

J7195 BeneFIX (Factor IX recombinant)

J0490 Benlysta (belimumab)

J0597 Berinert (C1 esterase inhibitor)

J9229 Besponsa (inotuzumab)

J9050 BICNU/Carmustine

J9040 Bleomycin

J9039 Blincyto (blinatumomab)

J1740 Boniva injection (ibandronate)

J0585 Botox (onaBotulinum toxin type A)

J0567 Brineura (Cerliponase Alfa)

J9206 Camptosar/Irinotecan

J9045 Carboplatin

J1786 Cerezyme (imiglucerase) Professional Homecare

J0717 Cimzia (certolizumab)

J2786 Cinqair (reslizumab)

J0598 Cinryze (C1 esterase inhibitor)

J9060 Cisplatin

J9065 Cladribine

J9027 Clolar (clofarabine)

J7175 Coagadex (factor X, human)

Q9977 Compounded Drugs

J7180 Corifact (Factor XIII)

J9120 Cosmegen/Dactinomycin

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PHARMACY J-CODES





J0584 Crysvita (burosumab-twza)

J1555 Cuvitru (IVIG subcutaneous)

J9070 Cyclophosphamide

J9308 Cyramza (ramucirumab) Biologics

J9100 Cytarabine

J9130 Dacarbazine

J0894 Dacogen (decitabine)

J9145 Darzalex (daratumumab)

J9150 Daunorubicin

J1096/C9399 Dextenza (dexamethasone)

J1095 Dexycu (dexamethasone)

Q2050 Doxil (doxorubicin, liposomal)

J7318 Durolane (hyaluronic acid)

J0586 Dysport (abobotulinumtoxinA)

J3490 Egrifta (tesamorelin) CVS/CareMark, Prescription Solutions, Right Source, Walgreen

J1743 Elaprase (idursulfase)

J3060 Elelyso (taliglucerase) Dohmen

J9175 Elliotts B

J7205 Eloctate (Factor VIII -recombinant)

J9263 Eloxatin (oxaliplatin)

J9269/C9399 Elzonris (tagraxofusp)

J9176 Empliciti (elotuzumab)

J3380 Entyvio (vedolizumab)

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PHARMACY J-CODES





J9178 Epirubicin

J9055 Erbitux (cetuximab)

J9019 Erwinaze (asparaginase)

J7323 Euflexxa (sodium hyauronate)

C9399/J3111 Evenity (romosozumab)

J9245 Evomela/Alkeran/Melphalan

J1428 Exondys 51 (eteplirsen)

J0178 Eylea (Aflibercept Ophthalmic)

J0180 Fabrazyme (agalsidase beta) Professional Homecare

J7194 Factor IX

J7190-J7192, Q9975 Factor VIII antihemophilic factor

J7180 Factor XIII

J0517 Fasenra (benralizumab)

J9395 Faslodex (fulvestrant)

J1744 Firazyr (Icatibant Acetate)

J9155 Firmagon (degarelix)

J1325 Flolan (epoprostenol)

J9200 Floxuridine

J9185 Fludarabine

J9307 Folotyn (pralatrexate)

Q5108 Fulphila (pegfilgrastim)

J9210/C9399 Gamifant (emapalumab-izsg)

J3490 Gattex (teduglutide)

J9301 Gazyva (obinutuzumab)

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PHARMACY J-CODES





J7326 Gel-One (hyaluronic acid)

J7328 Gelsyn-3 (hyaluronic acid)

J9201 Gemcitabine

J7320 GenVisc (hyaluronic acid)

J0257 Glassia (Alpha-1-Proteinase Inhibitor–Human)

J1447 Granix (tbo-filgrastim)

J0599 Haegarda (C1 Inhibitor, Human)

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)

C9399 Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

Q5113 Herzuma (trastuzumab-pkrb)

J1559 Hizentra (IVIG)

J0800 HP Acthar (corticotropin)

J7187 Humate-P (Von Willebrand factor)

J7321 Hyalgan (sodium hyaluronate)

J9351 Hycamtin/topotecan

J7320 Hymovis (hyaluronic acid)

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PHARMACY J-CODES





J1575 Hyqvia (IVIG subcutaneous)

J9211 Idamycin/Idarubicin

J7202 Idelvion (factor IX, albumin fusion protein, recombinant)

J9208 Ifex/ifosfamide

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)

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

IVIG (Immune Globulin liquid)

J1566 IVIG (Immune Globulin powder)

J9207 Ixempra (ixabepilone)

Q5109 Ixifi (infliximab-qbtx)

J7195 Ixinity (Factor IX recombinant)

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PHARMACY J-CODES





J7316 Jetrea (ocriplasmin)

J9043 Jevtana (cabazitaxel)

C9399/J7199 Jivi (Antihemophilic Factor, Recombinant (Pegylated))

J9354 Kadcyla (ado-trastuzumab)

J1290 Kalbitor (ecallantide)

Q5117 Kanjinti (trastuzumab - anns)

J2840 Kanuma (sebelipase alpha)

J9271 Keytruda (pembrolizumab)

J3490/C9043 Khapzory (LEVOleucovorin Calcium)

J7192 Kogenate FS (antihemophilic factor)

J7211 Kovaltry (Factor VIII)

J2507 Krystexxa (pegloticase)

Q2042 Kymriah (Tisagenlecleucel)

J9047 Kyprolis (carfilzomib)

J9285 Lartruvo (olaratumab)

J0202 Lemtrada (alemtuzumab)

J0640 Leucovorin

J2820 Leukine (sargramostim GM-CSF)

J0641 LEVOleucovorin

J9119/C9399 Libtayo (cemiplimab-rwlc)

Q2049 Lipodox (doxorubicin liposomal)

J2778 Lucentis (ranibizumab Intravitreal)

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PHARMACY J-CODES





J0221 Lumizyme (alglucosidase alfa)

J9313/C9399 Lumoxiti (Moxetumomab Pasudotox-tdfk)

A9513 Lutathera

J3398 Luxturna

J2503 Macugen (pegaptanib)

J9371 Marqibo (vincristine)

J3397 Mepsevii (vestronidase alfa-vjbk)

J9209 Mesna

J9293 Mitoxantrone

J7190 Monoclate P (antihemophilic factor)

J7193 Mononine (Factor IX (Human))

J7327 Monovisc (hyaluronic acid)

J2562 Mozobil (plerixaflor)

J9280 Mutamycin/mitomycin

Q5107 Mvasi (bevacizumab-awwb)

J9203 Mylotarg (Gemtuzumab Ozogamicin)

J0587 Myobloc (botulinum toxin type B)

J1458 Naglazyme (galsulfase)

J9390 Navelbine/Vinorelbine

J2505 Neulasta (pegfilgrastim)

J1442 Neupogen (filgrastim)

J9268 Nipent

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PHARMACY J-CODES





Q5110 Nivestym (filgrastim)

J7182 Novoeight (antihemophilic factor)

J7189 Novoseven (antihemophilic factor VIIa)

J2796 Nplate (romiplostim)

J2182 Nucala (mepolizumab)

J0485 Nulojix (belatacept)

J7209 Nuwiq (antihemophilic factor)

J7188 Obizur (Antihemophilic Factor VIII)

J2350 Ocrevus (ocrelizumab)

Q5114 Ogivri (trastuzumab-dkst, biosimilar)

J9266 Oncaspar

J9205 Onivyde (Irinotecan Liposomal)

C9036/J0222 Onpattro (Patisiran)

Q5112 Ontruzant (trastuzumab-dttb)

J9299 Opdivo (nivolumab)

J0129 Orencia (abatacept)

J7324 Orthovisc (hyaluronan)

J3490 Otrexup (methotrexate)

J7312 Ozurdex (dexamethasone implant)

J9267 Paclitaxel

J0606 Parsabiv (etelcalcetide)

J9306 Perjeta (pertuzumab)

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PHARMACY J-CODES





J9600 Photofrin

J9999/C9399 Polivy (Polatuzumab Vedotin)

J9295 Portrazza (necitumumab)

C9038/J9204 Poteligeo (Mogamulizumab-kpkc)

J2278 Prialt (ziconotide) Bioscrip

J0570 Probuphine Implant (buprenorphine)

J7194 Profilnine/SD (Factor IX Complex)

J0256 Prolastin (alpha-1 proteinase inhibitor)

Dohmen

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)

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PHARMACY J-CODES





J3590/C9399 Revcovi (elapegademase)

J7178 RiaSTAP (fibrinogen concentrate)

J9312 Rituxan (rituximab)

J9311 Rituxan Hycela (rituximab/hyaluronidase)

J7200 Rixubis (Factor IX)

J0596 Ruconest (C1 Esterase Inhibitor (Recombinant)

J0604 Sensipar (cinacalcet) Not Covered

J2502 Signifor (pasireotide)

J1602 Simponi ARIA (golimumab)

J1300 Soliris (ecuzliumab)

J1930 Somatuline Depot (lanreotide)

J2326 Spinraza (nusinersen)

J3490 Spravato™ (esketamine hydrochloride)

J3357, J3358 Stelara (ustekinumab) Stelara is a pharmacy benefit

J7321 Supartz (hyaluronic acid)

J9226 Supprelin LA (histrelin implant)

J2860 Sylvant (siltuximab)

J3490 Synagis (palivizumab)

J7331 Synojoynt (hyaluronic acid)

J9262 Synribo (omacetaxine) Diplomate

J7325 Synvisc (3 injection series)

J7325 Synvisc One (1 injection)

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PHARMACY J-CODES





C9399/J0593 Takhzyro (Lanadelumab-flyo Injection)

J9171 Taxotere/Docetaxel

C9022 Tecentriq (atezolizumab)

J9328 Temodar Injection (temozolomide)

Q2017 Teniposide

J9340 Tepadina (thiotepa)

J3490 Testopel (testosterone implant)

WALGREEN

J3240 Thyrogen (thyrotropin) Thyrogen is a Pharmacy benefit

J9031 Tice BCG

J9181 Toposar/Etoposide

J9330 Torisel (temsirolimus)

Q5116 Trazimera (trastuzumab – qyyp)

J9033 Treanda (bendamustine)

J3315 Trelstar

J1628 Tremfya (guselkumab)

J7181 Tretten (Coagulation Factor XIII)

J7332 Triluron (hyaluronic acid)

J7329 TriVisc (hyaluronic Acid)

J1746 Trogarzo (Ibalizumab-uiyk)

Q5115 Truxima (rituximab-abbs)

J2323 Tysabri (natalizumab)

J7686 Tyvaso (treprostinil)

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PHARMACY J-CODES





Q5111 Udenyca (pegfilgrastim-cbqv)

J1303/C9399 Ultomiris (ravulizumab)

J9999, C9399 Unituxin (dinutuximab)

J9357 Valstar

J9225 Vantas (histrelin implant)

J9303 Vectibix (panitumumab)

J9041/J9044 Velcade (bortezomib)

Q4074 Ventavis (iloprost)

J9025 Vidaza (azacitidine)

J1322 Vimizim (elosulfase alfa)

J9360 Vinblastine

J9370 Vincasar/Vincristine

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)

Nuclear Medicine and Hospital Clinics

J2357 Xolair (omalizumab) Xolair is a Pharmacy benefit

J7185 Xyntha (antihemophilic factor)

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PHARMACY J-CODES





J9228 Yervoy (ipilimumab)

Q2041 Yescarta (Axicabtagene Ciloleucel)

J9352 Yondelis (trabectedin)

J7314 Yutiq (fluocinolone intravitreal)

J9400 Zaltrap (ziv-aflibercept)

J9320 Zanosar

Q5101 Zarxio (filgrastim)

J0256 Zemaira (Alpha-1 proteinase inhibitor)

A9543 Zevalin (ibritumomab tiuxetan)

J3304 Zilretta (triamcinolone acetonide)

J0565 Zinplava (bezlotoxumab)

Q5118 Zirabev (bevacizumab – bvcr)

J9202 Zoladex

J3590, C9399 Zolgensma (onasemnogene abeparvovec-xioi)

J3490, C9399 Zulresso (Brexanolone)

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