| HCPCS codes | Brand name | Generic name | HCPCS Description | Requirement | Requirement effective date | Clinical Category |
| J9264 | ABRAXANE | paclitaxel | Injection, paclitaxel protein-bound particles, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J3262 | ACTEMRA | tocilizumab | INJECTION, TOCILIZUMAB, 1 MG | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J0800 | ACTHAR | corticotropin | Injection, corticotropin, up to 40 units | Precertification Notification | 1/1/2021 | Endocrine Disorders |
| J2504 | ADAGEN | pegademase bovine | Injection, pegademase bovine, 25 iu | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J0791 | ADAKVEO | crizanlizumab-tmca | Inj crizanlizumab-tmca 5 mg | PA Request | 1/1/2023 | Sickle Cell Disease |
| J9042 | ADCETRIS | brentuximab | Brentuximab Vedotin, 1mg | PA Request | 1/1/2023 | Oncology |
| J9000 | ADRIAMYCIN | doxorubicin hcl | Injection, doxorubicin hydrochloride, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9190 | ADRUCIL | fluorouracil | Injection, fluorouracil, 500 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0172 | ADUHELM | aducanumab-avwa | Injection, aducanumab-avwa, 2 mg | Exclusion: Medical Necessity Review Required | 1/1/2022 | Antidementia Agent |
| J7192 | ADVATE | factor viii | Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified | Precertification Notification | 1/1/2021 | Hemophilia |
| J7207 | ADYNOVATE | factor viii | Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7210 | AFSTYLA | factor viii | Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J1454 | AKYNZEO | fosnetupitant / palonosetron | Injection, fosnetupitant 235 mg and palonosetron 0.25 mg | Precertification Notification | 8/1/2022 | Anti-emetics |
| J1931 | ALDURAZYME | laronidase | Injection, laronidase, 0.1 mg | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J9215 | ALFERON N | interferon, alfa-n3, (human leukocyte derived) | Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iu | Precertification Notification | 1/1/2021 | Oncology |
| J0220 | Alglucosidase alfa | Alglucosidase alfa | Injection, alglucosidase alfa, 10 mg, not otherwise specified | PA Request | 10/1/2022 | Enzyme Deficiency |
| J9305 | ALIMTA | pemetrexed | Injection, pemetrexed, not otherwise specified, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9057 | ALIQOPA | copanlisib | Inj., copanlisib, 1 mg | PA Request | 1/1/2023 | Oncology |
| J9245 | ALKERAN | melphalan hcl | Injection, melphalan hydrochloride, not otherwise specified, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J2469 | Aloxi | Palonosetron hcl | Injection, palonosetron hcl, 25 mcg | No PA/No Precert Required | N/A | Anti-emetics |
| J7186 | ALPHANATE | factor viii/von willebrand factor | Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7193 | ALPHANINE SD | factor ix | Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7201 | ALPROLIX | factor ix | Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7345 | AMELUZ | aminolevulinic acid hcl | Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg | Precertification Notification | 1/1/2021 | Actinic Keratosis |
| J0225 | Amvuttra | Vutrisiran | Injection, vutrisiran, 1 mg | PA Request | 11/1/23 | Amyloidosis |
| J0739 | Apretude | Cabotegravir | Injection, cabotegravir, 1 mg | Precertification Notification | 5/1/23 | HIV/AIDS |
| J0256 | ARALAST NP | alpha 1 proteinase inhibitor | Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J0881 | ARANESP | darbepoetin alfa | Injection, darbepoetin alfa, 1 microgram (non-esrd use) | Precertification Notification | 1/1/2021 | Anemia |
| J2430 | Aredia | Pamidronate disodium | Injection, pamidronate disodium, per 30 mg | No PA/No Precert Required | N/A | Osteoporosis |
| J9261 | ARRANON | nelarabine | Injection, nelarabine, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9017 | ARSENIC TRIOXIDE | arsenic trioxide | Injection, arsenic trioxide, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9302 | ARZERRA | ofatumumab | INJECTION, OFATUMUMAB, 10 MG | PA Request | 1/1/2023 | Oncology |
| 90283 | ASCENIV | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1554 | ASCENIV | immune globulin | Injection, immune globulin (asceniv), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J9118 | ASPARLAS | calaspargase pegol-mknl | Injection, calaspargase pegol-mknl, 10 units | Precertification Notification | 1/1/2021 | Oncology |
| J7196 | ATRYN | antithrombin | Injection, antithrombin recombinant, 50 i.u. | Precertification Notification | 1/1/2021 | Hereditary Antithrombin Deficiency |
| J9035 | AVASTIN | bevacizumab | Injection, bevacizumab, 10 mg | PA Request | 8/1/2022 | Oncology |
| J9035 | AVASTIN | bevacizumab | Injection, bevacizumab, 10mg | No PA required | 8/1/2022 | Ophthalmic Disorders |
| J3145 | AVEED | testosterone undecanoate | Injection, testosterone undecanoate, 1 mg | Precertification Notification | 1/1/2021 | Endocrine Disorders |
| Q5121 | Avsola | Infliximab-axxq | Injection, infliximab-axxq, biosimilar, (avsola), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| J9025 | AZACITIDINE | azacitidine | Injection, azacitidine, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9023 | BAVENCIO | avelumab | Injection, avelumab, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| 90585 | BCG VACCINE | bcg live | Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use | Precertification Notification | 1/1/2021 | Oncology/vaccine |
| J9032 | BELEODAQ | belinostat | Injection, belinostat, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9036 | BELRAPZO | bendamustine hcl | Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9036 | BENDAMUSTINE HCL | bendamustine hcl | Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9034 | BENDEKA | bendeka | Injection, bendamustine hcl (bendeka), 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7195 | BENEFIX | factor ix | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | Precertification Notification | 1/1/2021 | Hemophilia |
| J0490 | BENLYSTA IV | belimumab | Injection, belimumab, 10 mg | PA Request | 1/1/2023 | Systemic Lupus Erythematosus (SLE) |
| J0179 | BEOVU | Brolucizumab | Injection, brolucizumab-dbll, 1 mg | PA Request | 10/1/2022 | Macular Degeneration |
| J0597 | BERINERT | c1 esterase inhibitor | Injection, c-1 esterase inhibitor (human), berinert, 10 units | Precertification Notification | 1/1/2021 | Hereditary Angioedema |
| J9229 | BESPONSA | inotuzumab ozogamicin | Injection, inotuzumab ozogamicin, 0.1 mg | PA Request | 1/1/2023 | Oncology |
| Q5126 | Bevacizumab (Alymsys) | Bevacizumab-maly | Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg | No PA/No Precert Required | N/A | Oncology |
| J9050 | BICNU | carmustine | Injection, carmustine, 100 mg | Precertification Notification | 1/1/2021 | Oncology |
| 90283 | BIVIGAM | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1556 | BIVIGAM | immune globulin | Injection, immune globulin (bivigam), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J9037 | BLENREP | belantamab mafodotin-blmf | Injection, belantamab mafodotin-blmf, 0.5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9040 | BLEOMYCIN SULFATE | bleomycin sulfate | Injection, bleomycin sulfate, 15 units | Precertification Notification | 1/1/2021 | Oncology |
| J9039 | BLINCYTO | blinatumomab | Injection, blinatumomab, 1 microgram | PA Request | 1/1/2022 | Oncology |
| J1740 | Boniva | Ibandronate sodium | Injection, ibandronate sodium, 1 mg | No PA/No Precert Required | N/A | Osteoporosis |
| J9046 | Bortezomib (Velcade Biosimilar) | Bortezomib | Injection, bortezomib, (dr. reddy's), not therapeutically equivalent to j9041, 0.1 mg ((biosimilar for VELCADE) | No PA/No Precert Required | N/A | Oncology |
| J9048 | Bortezomib (Velcade Biosimilar) | Bortezomib | Injection, bortezomib (fresenius kabi), not therapeutically equivalent to j9041, 0.1 mg (biosimilar for VELCADE) | No PA/No Precert Required | N/A | Oncology |
| J9049 | Bortezomib (Velcade Biosimilar) | Bortezomib | Injection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg (biosimilar for VELCADE) | No PA/No Precert Required | N/A | Oncology |
| J0585 | BOTOX | onabotulinumtoxina | Injection, onabotulinumtoxina, 1 unit | PA Request | 6/1/2022 | Neurotoxins |
| J0567 | BRINEURA | cerliponase alfa | Injection, cerliponase alfa, 1 mg | PA Request | 1/1/2022 | Enzyme Deficiency |
| J0594 | BUSULFAN | busulfan | injection, busulfan, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| Q5124 | Byooviz | Ranibizumab-nuna | Injection, ranibizumab-nuna, biosimilar, (byooviz) | No PA/No Precert Required | N/A | Macular Degeneration |
| J9206 | CAMPTOSAR | irinotecan | Injection, irinotecan, 20 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9045 | CARBOPLATIN | carboplatin | Injection, carboplatin, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9050 | CARMUSTINE | carmustine | Injection, carmustine, 100 mg | Precertification Notification | 1/1/2021 | Oncology |
| J2724 | CEPROTIN | protein c concentrate, IV, human | Injection, protein c concentrate, intravenous, human, 10 iu | Precertification Notification | 1/1/2021 | Severe Congenital Protein C Deficiency |
| J1786 | CEREZYME | Imiglucerase | Injection, imiglucerase, 10 units | PA Request | 10/1/2022 | Enzyme Deficiency |
| J0740 | CIDOFOVIR | cidofovir | Injection, cidofovir, 375 mg | Precertification Notification | 1/1/2021 | Anti-Infective Therapy |
| J0717 | CIMZIA | certolizumab | Certolizumab pegol inj 1mg | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J2786 | CINQAIR | reslizumab | Injection, reslizumab, 1 mg | PA Request | 8/1/2022 | Asthma |
| J0598 | CINRYZE | c1 esterase inhibitor | Injection, c-1 esterase inhibitor (human), cinryze, 10 units | Precertification Notification | 1/1/2021 | Hereditary Angioedema |
| J9060 | CISPLATIN | cisplatin | Injection, cisplatin, powder or solution, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9065 | CLADRIBINE | cladribine | Injection, cladribine, per 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9027 | CLOFARABINE | clofarabine | Injection, clofarabine, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9027 | CLOLAR | clofarabine | Injection, clofarabine, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7175 | COAGADEX | factor x | Injection, factor x, (human), 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7180 | CORIFACT | factor xiii | Injection, factor xiii (antihemophilic factor, human), 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J9120 | COSMEGEN | dactinomycin | Injection, dactinomycin, 0.5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0584 | CRYSVITA | burosumab | Injection, burosumab-twza 1 mg | PA Request | 1/1/2023 | Metabolic Conditions |
| J1551 | CUTAQUIG | immune globulin (cutaquig) | Injection, immune globulin (cutaquig), 100 mg | Not Covered | 7/1/2022 | Immunodeficiency |
| 90284 | CUVITRU | immune globulin | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1555 | CUVITRU | immune globulin | Injection, immune globulin (cuvitru), 100 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J9070 | CYCLOPHOSPHAMIDE | cyclophosphamide | Cyclophosphamide, 100 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9071 | CYCLOPHOSPHAMIDE | cyclophosphamide | Injection, cyclophosphamide, (auromedics), 5 mg | Precertification Notification | 8/1/2022 | Oncology |
| J9308 | CYRAMZA | ramucirumab | Injection, ramucirumab, 5 mg | PA Request | 1/1/2023 | Oncology |
| J9100 | CYTARABINE | cytarabine | Injection, cytarabine, 100 mg | Precertification Notification | 1/1/2021 | Oncology |
| J1570 | CYTOVENE | ganciclovir sodium | Injection, ganciclovir sodium, 500 mg | Precertification Notification | 1/1/2021 | Anti-Infective Therapy |
| J9130 | DACARBAZINE | dacarbazine | Dacarbazine, 100 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0894 | DACOGEN | decitabine | Injection, decitabine, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9120 | DACTINOMYCIN | dactinomycin | Injection, dactinomycin, 0.5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9348 | DANYELZA | naxitamab-gqgk | Injection, naxitamab-gqgk, 1 mg | PA Request | 1/1/2022 | Oncology |
| J9145 | DARZALEX | daratumumab | Injection, daratumumab 10 mg | PA Request | 1/1/2023 | Oncology |
| J9144 | DARZALEX FASPRO | daratumumab / hyaluronidase-fihj | Injection, daratumumab, 10 mg and hyaluronidase-fihj | PA Request | 1/1/2023 | Oncology |
| J9150 | DAUNORUBICIN HCL | daunorubicin | Injection, daunorubicin, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9151 | DAUNOXOME | daunorubicin citrate, liposomal | Injection, daunorubicin citrate, liposomal formulation, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0894 | DECITABINE | decitabine | Injection, decitabine, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0893 | Decitabine | Decitabine | Injection, decitabine (sun pharma) not therapeutically equivalent to j0894, 1 mg | No PA/No Precert Required | N/A | Oncology |
| J9098 | DEPOCYT | cytarabine liposome | Injection, cytarabine liposome, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J1190 | DEXRAZOXANE HCL | dexrazoxane hcl | Injection, dexrazoxane hydrochloride, per 250 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| J9171 | DOCEFREZ | docetaxel | Injection, docetaxel, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9171 | DOCETAXEL | docetaxel | Injection, docetaxel, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| Q2050 | DOXIL | doxorubicin hcl liposomal | Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9000 | DOXORUBICIN HCL | doxorubicin hcl | Injection, doxorubicin hydrochloride, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| Q2050 | DOXORUBICIN HCL LIPOSOMAL | doxorubicin hcl liposomal | Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7318 | DUROLANE | Hyaluronan or derivative | Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg | PA Request | 10/1/2022 | Osteoarthritis |
| J7351 | DURYSTA | bimatoprost | Injection, bimatoprost, intracameral implant, 1 microgram | Precertification Notification | 1/1/2021 | Ophthalmic Disorders |
| J0586 | DYSPORT | abobotulinumtoxina | Injection, abobotulinumtoxina, 5 units | PA Request | 6/1/2022 | Neurotoxins |
| J1743 | ELAPRASE | idursulfase | Injection, idursulfase, 1 mg | PA Request | 5/1/2023 | Enzyme Deficiency |
| J3060 | ELELYSO | Taliglucerase Alfa | Injection, taliglucerase alfa, 10 units | PA Request | 10/1/2022 | Enzyme Deficiency |
| J9217 | ELIGARD | leuprolide acetate (depot) | Leuprolide acetate (for depot suspension), 7.5 mg | PA Request | 1/1/2023 | Oncology |
| J2783 | ELITEK | rasburicase | Injection, rasburicase, 0.5 mg | Precertification Notification | 1/1/2021 | Chemo Protectant (TLS) |
| J9178 | ELLENCE | oxaliplatin | Injection, epirubicin hcl, 2 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7205 | ELOCTATE | factor viii | Injection, factor viii fc fusion protein (recombinant), per iu | Precertification Notification | 1/1/2021 | Hemophilia |
| J9269 | ELZONRIS | tagraxofusp-erzs | Injection, tagraxofusp-erzs, 10 micrograms | PA Request | 5/1/2023 | Oncology |
| J9176 | EMPLICITI | elotuzumab | Injection, elotuzumab, 1mg | PA Request | 1/1/2023 | Oncology |
| J1438 | ENBREL | etanercept | Injection, etanercept, 25 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) | PA Request | 8/1/2022 | Auto-inflammatory Conditions |
| J9358 | ENHERTU | fam-trastuzumab deruxtecan-nxki | Inj fam-trastu deru-nxki 1mg | PA Request | 1/1/2023 | Oncology |
| J1302 | ENJAYMO | sutimlimab-jome | Inj, sutimlimab-jome, 10 mg | Not Covered | 7/1/2022 | Oncology |
| J3380 | ENTYVIO | Vedolizumab | Injection, vedolizumab, 1 mg | PA Request | 10/1/2022 | Auto-inflammatory Conditions |
| J9178 | EPIRUBICIN HCL | oxaliplatin | Injection, epirubicin hcl, 2 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0885 | EPOGEN | epoetin alfa | Injection, epoetin alfa, (for non-esrd use), 1000 units | PA Request | 8/1/2022 | Anemia |
| Q4081 | EPOGEN | epoetin alfa | Injection, epoetin alfa, 100 units (for esrd on dialysis) | PA Request | 8/1/2022 | Anemia (Dialysis) |
| J1325 | EPOPROSTENOL SODIUM | epoprostenol | Injection, epoprostenol, 0.5 mg | Precertification Notification | 1/1/2021 | Pulmonary Arterial Hypertension (PAH) |
| J9055 | ERBITUX | cetuximab | Injection, Cetuximab, 10 Mg | PA Request | 1/1/2023 | Oncology |
| J9019 | ERWINAZE | asparaginase (erwinaze) | Injection, asparaginase (erwinaze), 1,000 iu | Precertification Notification | 1/1/2021 | Oncology |
| J7204 | ESPEROCT | factor viii | Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu | Precertification Notification | 1/1/2021 | Hemophilia |
| J0207 | ETHYOL | amifostine | Injection, amifostine, 500 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| J9181 | ETOPOPHOS | etoposide | Injection, etoposide, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9181 | ETOPOSIDE | etoposide | Injection, etoposide, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7323 | Euflexxa | Hyaluronan or derivative | Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose | No PA/No Precert Required | N/A | Osteoarthritis |
| J3111 | EVENITY | romosozumab | Inj. romosozumab-aqqg 1 mg | PA Request | 1/1/2023 | Osteoporosis |
| J1305 | Evkeeza | evinacumab-dgnb | Injection, evinacumab-dgnb, 5 mg | PA Request | 11/1/2023 | Hypercholesterolemia |
| J9246 | EVOMELA | melphalan hcl | Injection, melphalan (evomela), 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J1428 | EXONDYS 51 | eteplirsen | Injection, eteplirsen, 10 mg | Precertification Notification | 1/1/2021 | Duchenne Muscular Dystrophy |
| J0178 | EYLEA | Aflibercept | Injection, aflibercept, 1 mg | PA Request | 10/1/2022 | Macular Degeneration |
| J0180 | FABRAZYME | agalsidase beta | Injection, agalsidase beta, 1 mg | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J0517 | FASENRA | benralizumab | Injection, benralizumab, 1 mg | PA Request | 8/1/2022 | Asthma |
| J9395 | FASLODEX | fulvestrant | Injection, fulvestrant, 25 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7198 | FEIBA | anti-inhibitor | Anti-inhibitor, per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7198 | FEIBA NF | anti-inhibitor | Anti-inhibitor, per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| Q0138, Q0139 | Feraheme | Ferumoxytol | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) | No PA/No Precert Required | N/A | Anemia |
| J2916 | Ferrlecit | Sodium Ferric Gluconate | Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg | No PA/No Precert Required | N/A | Anemia |
| Q0138 | FERUMOXYTOL | ferumoxytol | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) | Precertification Notification | 1/1/2022 | Anemia |
| Q0139 | FERUMOXYTOL | ferumoxytol | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) | Precertification Notification | 1/1/2022 | Anemia (dialysis) |
| J7177 | FIBRYGA | human fibrinogen concentrate | Injection, human fibrinogen concentrate (fibryga), 1 mg | Precertification Notification | 1/1/2021 | Hemophilia |
| J9155 | FIRMAGON | degarelix | INJECTION, DEGARELIX, 1 MG | PA Request | 1/1/2023 | Oncology |
| 90283 | FLEBOGAMMA DIF | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1572 | FLEBOGAMMA DIF | immune globulin | Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g., liquid), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1325 | FLOLAN | epoprostenol | Injection, epoprostenol, 0.5 mg | Precertification Notification | 1/1/2021 | Pulmonary Arterial Hypertension (PAH) |
| J9200 | FLOXURIDINE | floxuridine | Injection, floxuridine, 500 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9185 | FLUDARABINE PHOSPHATE | fludarabine phosphate | Injection, fludarabine phosphate, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9190 | FLUOROURACIL | fluorouracil | Injection, fluorouracil, 500 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9393 | Fluvestrant (Faslodex Generic) | Fulvestrant | Injection, fulvestrant (teva) not therapeutically equivalent to j9395, 25 mg | No PA/No Precert Required | N/A | Oncology |
| J9394 | Fluvestrant (Faslodex Generic) | Fulvestrant | Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg | No PA/No Precert Required | N/A | Oncology |
| J9307 | FOLOTYN | pralatrexate | Injection, pralatrexate, 1 mg | PA Request | 1/1/2022 | Oncology |
| Q5108 | Fulphila | Pegfilgrastim-jmdb | Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg | No PA/No Precert Required | N/A | Neutropenia |
| J9395 | FULVESTRANT | fulvestrant | Injection, fulvestrant, 25 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0641 | FUSILEV | levoleucovorin | Injection, levoleucovorin, not otherwise specified, 0.5 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| J9331 | Fyarro | sirolimus | Injection, sirolimus protein-bound particles, 1 mg | Precertification Notification | 5/1/23 | Oncology |
| 90281 | GAMASTAN | immune globulin | Immune Globulin (Ig), human, for intramuscular use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1460 | GAMASTAN | immune globulin | Injection, gamma globulin, intramuscular, 1 cc | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1560 | GAMASTAN | immune globulin | Injection, gamma globulin, intramuscular, over 10 cc | Precertification Notification | 1/1/2021 | Immunodeficiency |
| 90283 | GAMMAGARD | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| 90284 | GAMMAGARD | immune globulin | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1566 | GAMMAGARD | immune globulin | Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1569 | GAMMAGARD | immune globulin | Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| 90283 | GAMMAKED | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| 90284 | GAMMAKED | immune globulin | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1561 | GAMMAKED | immune globulin | Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| 90283 | GAMMAPLEX | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1557 | GAMMAPLEX | immune globulin | Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| 90283 | GAMUNEX-C | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| 90284 | GAMUNEX-C | immune globulin | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1561 | GAMUNEX-C | immune globulin | Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1570 | GANCICLOVIR | ganciclovir sodium | Injection, ganciclovir sodium, 500 mg | Precertification Notification | 1/1/2021 | Anti-Infective Therapy |
| J9301 | GAZYVA | obinutuzumab | Injection, obinutuzumab, 10 mg | PA Request | 1/1/2023 | Oncology |
| J7326 | GEL-ONE | Hyaluronan or derivative | Hyaluronan or derivative, gel-one, for intra-articular injection, per dose | PA Request | 10/1/2022 | Osteoarthritis |
| J7328 | GELSYN-3 | Hyaluronan or derivative | Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg | PA Request | 10/1/2022 | Osteoarthritis |
| J9201 | GEMCITABINE HCL | gemcitabine hcl | Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7320 | GENVISC 850 | Hyaluronan or derivative | Hyaluronan or derivative, genvisc 850, for intra-articular injection, 1 mg | PA Request | 10/1/2022 | Osteoarthritis |
| J0223 | GIVLAARI | givosiran | Injection, givosiran, 0.5 mg | Precertification Notification | 1/1/2021 | Acute Hepatic Porphyria |
| J0257 | GLASSIA | alpha 1 proteinase inhibitor | Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J1447 | GRANIX | tbo-filgrastim | Injection, tbo-filgrastim, 1 microgram | Precertification Notification | 1/1/2021 | Neutropenia |
| J9179 | HALAVEN | eribulin mesylate | Injection, eribulin mesylate, 0.1 mg | PA Request | 1/1/2023 | Oncology |
| J7192 | HELIXATE FS | factor viii | Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified | Precertification Notification | 1/1/2021 | Hemophilia |
| J7170 | HEMLIBRA | Emicizumab | Injection, emicizumab-kxwh, 0.5 mg | PA Request | 10/1/2022 | Hemophilia |
| J7190 | HEMOFIL M | factor viii | Factor viii (antihemophilic factor, human) per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J9355 | HERCEPTIN | trastuzumab | Injection, trastuzumab, excludes biosimilar, 10 mg | PA Request | 8/1/2022 | Oncology |
| J9356 | HERCEPTIN HYLECTA | trastuzumab / hyaluronidase-oysk | Injection, trastuzumab, 10 mg and hyaluronidase-oysk | PA Request | 8/1/2022 | Oncology |
| Q5113 | Herzuma | Trastuzumab-pkrb | Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg | No PA/No Precert Required | N/A | Oncology |
| 90284 | HIZENTRA | immune globulin | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1559 | HIZENTRA | immune globulin | Injection, immune globulin (hizentra), 100 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J7187 | HUMATE-P | von willebrand factor | Injection, von willebrand factor complex (humate-p), per iu vwf:rco | Precertification Notification | 1/1/2021 | Hemophilia |
| J0135 | HUMIRA | adalimumab | Injection, adalimumab, 20 mg | PA Request | 8/1/2022 | Auto-inflammatory Conditions |
| J7321 | Hyalgan | Hyaluronan or derivative | Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose | No PA/No Precert Required | N/A | Osteoarthritis |
| J9351 | HYCAMTIN | topotecan | Injection, topotecan, 0.1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J1729 | HYDROXYPROGESTERONE CAPROATE | hydroxyprogesterone caproate | Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7322 | HYMOVIS | Hyaluronan or derivative | Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg | PA Request | 10/1/2022 | Osteoarthritis |
| J1575 | HYQVIA | immune globulin | Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immune globulin | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J9211 | IDAMYCIN PFS | idarubicin hcl | Injection, idarubicin hydrochloride, 5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9211 | IDARUBICIN HCL | idarubicin hcl | Injection, idarubicin hydrochloride, 5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7202 | IDELVION | factor ix | Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J9208 | IFEX | ifosfamide | Injection, ifosfamide, 1 gram | Precertification Notification | 1/1/2021 | Oncology |
| J9208 | IFOSFAMIDE | ifosfamide | Injection, ifosfamide, 1 gram | Precertification Notification | 1/1/2021 | Oncology |
| J0638 | ILARIS | canakinumab | INJECTION, CANAKINUMAB, 1 MG | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J3245 | ILUMYA | tildrakizumab | INJ., TILDRAKIZUMAB, 1 MG | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J7313 | ILUVIEN | iluvien | Inj., iluvien, 0.01 mg | PA Request | 1/1/2023 | Ophthalmic Disorders |
| J9173 | IMFINZI | durvalumab | Inj., durvalumab, 10 mg | PA Request | 1/1/2023 | Oncology |
| J1750 | Infed | Iron Dextran | Injection, iron dextran, 50 mg | No PA/No Precert Required | N/A | Anemia |
| Q5103 | Inflectra | Infliximab-dyyb | Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| J1745 | INFLIXIMAB | infliximab, excludes biosimilar | Injection, infliximab, excludes biosimilar, 10 mg | PA Request | 8/1/2022 | Auto-inflammatory Conditions |
| J9198 | INFUGEM | gemcitabine hcl | Injection, gemcitabine hydrochloride, (infugem), 100 mg | Precertification Notification | 1/1/2021 | Oncology |
| J1439 | INJECTAFER | Ferric carboxymaltose | Injection, ferric carboxymaltose, 1 mg | PA Request | 10/1/2022 | Anemia |
| J9214 | INTRON A | interferon, alfa-2b | Injection, interferon, alfa-2b, recombinant, 1 million units | Precertification Notification | 1/1/2021 | Oncology |
| J9206 | IRINOTECAN HCL | irinotecan | Injection, irinotecan, 20 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9319 | ISTODAX | romidepsin | Injection, romidepsin, lyophilized, 0.1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9207 | IXEMPRA | ixabepilone | Injection, ixabepilone, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| Q5109 | Ixifi | Infliximab-qbtx | Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| J7195 | IXINITY | factor ix | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | Precertification Notification | 1/1/2021 | Hemophilia |
| J9281 | JELMYTO | mitomycin | Mitomycin pyelocalyceal instillation, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9043 | JEVTANA | cabazitaxel | Injection, cabazitaxel, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7208 | JIVI | factor viii | Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J9354 | KADCYLA | ado-trastuzumab emtansine | Injection, ado-trastuzumab emtansine, 1 mg | PA Request | 1/1/2023 | Oncology |
| J1290 | KALBITOR | ecallantide | Injection, ecallantide, 1 mg | Precertification Notification | 1/1/2021 | Hereditary Angioedema |
| Q5117 | Kanjinti | Trastuzumab-anns | Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg | No PA/No Precert Required | N/A | Oncology |
| J2840 | KANUMA | sebelipase alfa | Injection, sebelipase alfa, 1 mg | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J2425 | KEPIVANCE | palifermin | INJECTION PALIFERMIN 50 MICROGRAMS | PA Request | 1/1/2023 | Oncology |
| J9271 | KEYTRUDA | pembrolizumab | Injection, pembrolizumab, 1 mg | PA Request | 8/1/2022 | Oncology |
| J0642 | KHAPZORY | levoleucovorin | Injection, levoleucovorin (khapzory), 0.5 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| J9274 | KIMMTRAK | tebentafusp-tebn | Inj, tebentafusp-tebn, 1 mcg | PA Request | 1/1/2023 | Oncology |
| J7190 | KOATE | factor viii | Factor viii (antihemophilic factor, human) per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7192 | KOGENATE FS | factor viii | Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified | Precertification Notification | 1/1/2021 | Hemophilia |
| J0879 | KORSUVA | difelikefalin | Injection, difelikefalin, 0.1 microgram | Not Covered | 7/1/2022 | Oncology |
| J7211 | KOVALTRY | factor viii | Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J9047 | KRYPOLIS | carfilzomib | Injection, carfilzomib, 1 mg | PA Request | 1/1/2023 | Oncology |
| J2507 | KRYSTEXXA | pegloticase | Injection, pegloticase, 1 mg | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J1626 | Kytril | Granisetron hydrochloride | Injection, granisetron hydrochloride, 100 mcg | No PA/No Precert Required | N/A | Anti-emetics |
| J1932 | Lanreotide | Lanreotide | Injection, lanreotide, (cipla), 1 mg | No PA/No Precert Required | N/A | Endocrine Disorders |
| J9285 | LARTRUVO | olaratumab | Injection, olaratumab, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0202 | LEMTRADA | alemtuzumab | Injection, alemtuzumab, 1 mg | PA Request | 1/1/2023 | Multiple Sclerosis |
| J1306 | LEQVIO | Inclisiran | Injection, inclisiran, 1 mg | PA Request | 10/1/2022 | Hypercholesterolemia |
| J2820 | LEUKINE | sargramostim (gm-csf) | Injection, sargramostim (gm-csf), 50 mcg | Precertification Notification | 1/1/2021 | Neutropenia |
| J0641 | LEVOLEUCOVORIN CALCIUM | levoleucovorin | Injection, levoleucovorin, not otherwise specified, 0.5 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| J7308 | LEVULAN KERASTICK | aminolevulinic acid hcl | Aminolevulinic acid hcl for topical administration, 20%, single unit dosage form (354 mg) | Precertification Notification | 1/1/2021 | Actinic Keratosis |
| J9119 | LIBTAYO | cemiplimab-rwlc | Inj., cemiplimab-rwlc, 1 mg | PA Request | 1/1/2023 | Oncology |
| Q2049 | LIPODOX | doxorubicin hcl liposomal | Injection, doxorubicin hydrochloride, liposomal, imported lipodox, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J2778 | LUCENTIS | ranibizumab | Injection, ranibizumab, 0.1 mg | PA Request | 8/1/2022 | Macular Degeneration |
| J0221 | LUMIZYME | Alglucosidase alfa | Injection, alglucosidase alfa, (lumizyme), 10 mg | PA Request | 10/1/2022 | Enzyme Deficiency |
| J9313 | LUMOXITI | moxetumomab pasudotox-tdfk | Injection, moxetumomab pasudotox-tdfk, 0.01 mg | Precertification Notification | 1/1/2021 | Oncology |
| J1950 | LUPRON DEPOT | leuoprolide acetate depot | Injection, leuprolide acetate (for depot suspension), per 3.75 mg | PA Request | 1/1/2023 | Oncology |
| J9217 | LUPRON DEPOT | leuprolide acetate (depot) | Leuprolide acetate (for depot suspension), 7.5 mg | PA Request | 1/1/2023 | Oncology |
| J1954 | Lutrate | Leuprolide Acetate | Injection, leuprolide acetate for depot suspension (lutrate), 7.5 mg | Precertification Notification | 5/1/23 | Oncology |
| J2503 | MACUGEN | Pegaptanib | Injection, pegaptanib sodium, 0.3 mg | PA Request | 10/1/2022 | Macular Degeneration |
| J9371 | MARQIBO | vincristine sulfate liposome | Injection, vincristine sulfate liposome, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9245 | MELPHALAN HCL | melphalan hcl | Injection, melphalan hydrochloride, not otherwise specified, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J3397 | MEPSEVII | vestronidase alfa-vjbk | Injection, vestronidase alfa-vjbk, 1 mg | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J9209 | MESNA | mesna | Injection, mesna, 200 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| J9209 | MESNEX | mesna | Injection, mesna, 200 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| J9250 | METHOTREXATE | methotrexate sodium | Methotrexate sodium, 5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9260 | METHOTREXATE | methotrexate sodium | Methotrexate sodium, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0887 | MIRCERA | epoetin beta | Injection, epoetin beta, 1 microgram, (for esrd on dialysis) | Precertification Notification | 1/1/2021 | Anemia (Dialysis) |
| J0888 | MIRCERA | epoetin beta | Injection, epoetin beta, 1 microgram, (for non esrd use) | Precertification Notification | 1/1/2021 | Anemia |
| J9280 | MITOMYCIN | mitomycin | Injection, mitomycin, 5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9293 | MITOXANTRONE HCL | mitoxantrone hcl | Injection, mitoxantrone hydrochloride, per 5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9349 | MONJUVI | tafasitamab-cxix | Inj., tafasitamab-cxix | PA Request | 1/1/2023 | Oncology |
| J7190 | MONOCLATE-P | factor viii | Factor viii (antihemophilic factor, human) per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J1437 | MONOFERRIC | Ferric derisomaltose | Injection, ferric derisomaltose, 10 mg | PA Request | 10/1/2022 | Anemia |
| J7193 | MONONINE | factor ix | Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J7327 | MONOVISC | Hyaluronan or derivative | Hyaluronan or derivative, monovisc, for intra-articular injection, per dose | PA Request | 10/1/2022 | Osteoarthritis |
| J9280 | MUTAMYCIN | mitomycin | Injection, mitomycin, 5 mg | Precertification Notification | 1/1/2021 | Oncology |
| Q5107 | Mvasi | bevacizumab-awwb | Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg | No PA/No Precert Required | N/A | Oncology |
| J9203 | MYLOTARG | gemtuzumab ozogamicin | Injection, gemtuzumab ozogamicin, 0.1 mg | PA Request | 5/1/2023 | Oncology |
| J0587 | MYOBLOC | rimabotulinumtoxinb | Injection, rimabotulinumtoxinb, 100 units | PA Request | 6/1/2022 | Neurotoxins |
| J2916 | NA FERRIC GLUC CPLX IN SUCROSE | sodium ferric gluconate complex in sucrose | Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg | Precertification Notification | 1/1/2022 | Anemia |
| J1458 | NAGLAZYME | galsulfase | Injection, galsulfase, 1 mg | PA Request | 1/1/2023 | Enzyme Deficiency |
| J2325 | NATRECOR | nesiritide | Injection, nesiritide, 0.1 mg | Precertification Notification | 1/1/2021 | Cardiovascular Agents |
| J9390 | NAVELBINE | vinorelbine tartrate | Injection, vinorelbine tartrate, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9261 | NELARABINE | nelarabine | Injection, nelarabine, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J2506 | NEULASTA | pegfilgrastim, excludes biosimilar | Injection, pegfilgrastim, excludes biosimilar, 0.5 mg | PA Request | 8/1/2022 | Neutropenia |
| J2355 | NEUMEGA | oprelvekin | Injection, oprelvekin, 5 mg | Precertification Notification | 1/1/2021 | Hematopoietic Growth Factors |
| J1442 | NEUPOGEN | filgrastim (g-csf), excludes biosimilars | Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram | PA Request | 8/1/2022 | Neutropenia |
| J0219 | NEXVIAZYME | Avalglucosidase alfa-ngpt | Injection, avalglucosidase alfa-ngpt, 4 mg | PA Request | 10/1/2022 | Enzyme Deficiency |
| J9268 | NIPENT | pentostatin | Injection, pentostatin, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| Q5110 | Nivestym | Filgrastim-aafi | Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram | No PA/No Precert Required | N/A | Neutropenia |
| J7182 | NOVOEIGHT | factor viii | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | Precertification Notification | 1/1/2021 | Hemophilia |
| J7189 | NOVOSEVEN RT | factor viia | Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram | Precertification Notification | 1/1/2021 | Hemophilia |
| J2796 | NPLATE | romiplostim | INJECTION, ROMIPLOSTIM, 10 MICROGRAMS | PA Request | 1/1/2023 | Thrombocytopenia |
| J2182 | NUCALA | mepolizumab | Injection, mepolizumab, 1 mg | PA Request | 8/1/2022 | Asthma |
| J0485 | NULOJIX | belatacept | Injection, belatacept, 1 mg | PA Request | 1/1/2023 | Immunosuppressive Agents |
| J7209 | NUWIQ | factor viii | Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J0121 | NUZYRA | omadacycline | Injection, omadacycline, 1 mg | Precertification Notification | 1/1/2021 | Anti-Infective Therapy |
| Q5122 | Nyvepria | Pegfilgrastim-apgf | Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg | No PA/No Precert Required | N/A | Neutropenia |
| J7188 | OBIZUR | factor viii | Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J2350 | OCREVUS | Ocrelizumab | Injection, ocrelizumab, 1 mg | PA Request | 10/1/2022 | Multiple Sclerosis |
| 90283 | OCTAGAM | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1568 | OCTAGAM | immune globulin | Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| Q5114 | Ogivri | Trastuzumab-dkst | Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg | No PA/No Precert Required | N/A | Oncology |
| C9101 | Olinvyk | Oliceridine | Injection, oliceridine, 0.1 mg | Precertification Notification | 5/1/23 | Pain Management |
| J0890 | OMONYTYS | peginesatide | Injection, peginesatide, 0.1 mg (for esrd on dialysis) | Precertification Notification | 1/1/2021 | Hematopoietic Growth Factors |
| J9266 | ONCASPAR | pegaspargase | Injection, pegaspargase, per single dose vial | Precertification Notification | 1/1/2021 | Oncology |
| J9205 | ONIVYDE | irinotecan liposome | Injection, irinotecan liposome, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0222 | ONPATTRO | patisiran | Injection, patisiran, 0.1 mg | PA Request | 5/1/2023 | Amyloidosis |
| Q5112 | Ontruzant | Trastuzumab-dttb | Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg | No PA/No Precert Required | N/A | Oncology |
| J9299 | OPDIVO | nivolumab | Injection, nivolumab, 1 mg | PA Request | 8/1/2022 | Oncology |
| J9298 | Opdualag | Nivolumab/relatlimab | Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg | PA Request | 11/1/23 | Oncology |
| J0129 | ORENCIA | abatacept | Injection, abatacept, 10 mg | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J7324 | ORTHOVISC | Hyaluronan or derivative | Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose | PA Request | 10/1/2022 | Osteoarthritis |
| J9263 | OXALIPLATIN | oxaliplatin | Injection, oxaliplatin, 0.5 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0224 | OXLUMO | lumasiran | Injection, lumasiran, 0.5 mg | Precertification Notification | 8/1/2022 | Primary Hyperoxaluria |
| J7312 | OZURDEX | dexamethasone | Injection, dexamethasone, intravitreal implant, 0.1 mg | Precertification Notification | 1/1/2021 | Ophthalmic Disorders |
| J9267 | PACLITAXEL | paclitaxel | Injection, paclitaxel, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9177 | PADCEV | enfortumab vedotin-ejfv | Injection, enfortumab vedotin-ejfv, 0.25 mg | Precertification Notification | 1/1/2021 | Oncology |
| 90283 | PANZYGA | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1599 | PANZYGA | immune globulin | Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J9045 | PARAPLATIN | carboplatin | Injection, carboplatin, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9314 | Pemetrexed (Alimta Generic) | Pemetrexed | Injection, pemetrexed (teva) not therapeutically equivalent to J9305, 10 mg | No PA/No Precert Required | N/A | Oncology |
| J9304 | PEMFEXY | pemetrexed | Injection, pemetrexed (pemfexy), 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9306 | PERJETA | Pertuzumab | Injection, pertuzumab, 1 mg | PA Request | 10/1/2022 | Oncology |
| J9316 | PHESGO | pertuzumab / trastuzumab / hyaluronidase-zzxf | Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg | PA Request | 8/1/2022 | Oncology |
| J9600 | PHOTOFRIN | porfimer sodium | Injection, porfimer sodium, 75 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9309 | POLIVY | polatuzumab vedotin-piiq | Injection, polatuzumab vedotin-piiq, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9295 | PORTRAZZA | necitumumab | Injection, necitumumab, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9204 | POTELIGEO | mogamulizumab-kpkc | Inj, mogamulizumab-kpkc, 1 mg | PA Request | 1/1/2023 | Oncology |
| J2278 | PRIALT | ziconotide | Injection, ziconotide, 1 microgram | Precertification Notification | 1/1/2021 | Auto-inflammatory Conditions |
| 90283 | PRIVIGEN | immune globulin | Immune globulin (IgIV), human, for intravenous use | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J1459 | PRIVIGEN | immune globulin | Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg | Precertification Notification | 1/1/2021 | Immunodeficiency |
| J0885 | PROCRIT | epoetin alfa | Injection, epoetin alfa, (for non-esrd use), 1000 units | PA Request | 8/1/2022 | Anemia |
| Q4081 | PROCRIT | epoetin alfa | Injection, epoetin alfa, 100 units (for esrd on dialysis) | PA Request | 8/1/2022 | Anemia (Dialysis) |
| J7194 | PROFILNINE | factor ix | Factor ix, complex, per i.u. | Precertification Notification | 1/1/2021 | Hemophilia |
| J0256 | PROLASTIN-C | alpha 1 proteinase inhibitor | Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg | Precertification Notification | 1/1/2021 | Enzyme Deficiency |
| J9015 | PROLEUKIN | aldesleukin | Injection, aldesleukin, per single use vial | Precertification Notification | 1/1/2021 | Oncology |
| J0897 | PROLIA | denosumab | Injection, denosumab, 1 mg | PA Request | 6/1/2022 | Osteoporosis |
| J1301 | RADICAVA | edaravone | Injection, edaravone, 1 mg | PA Request | 1/1/2023 | Amyotrophic Lateral Sclerosis |
| J7203 | REBINYN | factor ix | Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu | Precertification Notification | 1/1/2021 | Hemophilia |
| J0896 | REBLOZYL | luspatercept-aamt | Inj luspatercept-aamt 0.25mg | PA Request | 1/1/2023 | Myelodysplastic Syndrome |
| J3489 | Reclast | Zoledronic acid | Injection, zoledronic acid, 1 mg | No PA/No Precert Required | N/A | Endocrine Disorders |
| J7192 | RECOMBINATE | factor viii | Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified | Precertification Notification | 1/1/2021 | Hemophilia |
| Q5125 | Releuko | Filgrastim-ayow, | Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram | No PA/No Precert Required | N/A | Neutropenia |
| J1745 | REMICADE | infliximab, excludes biosimilar | Injection, infliximab, excludes biosimilar, 10 mg | PA Request | 8/1/2022 | Auto-inflammatory Conditions |
| J3285 | REMODULIN | treprostinil | Injection, treprostinil, 1 mg | Precertification Notification | 1/1/2021 | Pulmonary Arterial Hypertension (PAH) |
| Q5104 | Renflexis | Infliximab-abda | Injection, infliximab-abda, biosimilar, (renflexis), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| Q5105, Q5106 | Retacrit | Infliximab-abda | Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units | No PA/No Precert Required | N/A | Anemia |
| Q5123 | Riabni | Rituximab-arrx | Injection, rituximab-arrx, biosimilar, (riabni), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| J7178 | RIASTAP | human fibrinogen concentrate | Injection, human fibrinogen concentrate, not otherwise specified, 1 mg | Precertification Notification | 1/1/2021 | Hemophilia |
| J9312 | RITUXAN | rituximab | Injection, rituximab, 10 mg | PA Request | 8/1/2022 | Oncology |
| J9311 | RITUXAN HYCELA | rituximab / hyaluronidase | Injection, rituximab 10 mg and hyaluronidase | PA Request | 8/1/2022 | Oncology |
| J7200 | RIXUBIS | factor ix | Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu | Precertification Notification | 1/1/2021 | Hemophilia |
| J9319 | ROMIDEPSIN | romidepsin | Injection, romidepsin, lyophilized, 0.1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J0596 | RUCONEST | c1 esterase inhibitor | Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units | Precertification Notification | 1/1/2021 | Hereditary Angioedema |
| Q5119 | Ruxience | Rituximab-pvvr | Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| J9061 | Rybrevant | amivantamab-vmjw | Injection, amivantamab-vmjw | PA Request | 11/1/2023 | Oncology |
| J2353 | SANDOSTATIN LAR DEPOT | octreotide depot | Injection, Octreotide, Depot Form for Intramuscular Injection, 1 Mg | PA Request | 1/1/2023 | Endocrine Disorders |
| J0491 | SAPHNELO | anifrolumab-fnia | Injection, anifrolumab-fnia, 1 mg | Not Covered | 7/1/2022 | Oncology |
| J9227 | SARCLISA | isatuximab-irfc | Injection, isatuximab-irfc, 10 mg | PA Request | 5/1/2023 | Oncology |
| J7352 | SCENESSE | afamelanotide | Afamelanotide implant, 1 mg | Precertification Notification | 1/1/2021 | Erythropoietic protoporphyria |
| J7212 | SEVENFACT | factor viia | Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram | Precertification Notification | 1/1/2021 | Hemophilia |
| J2502 | SIGNIFOR LAR | pasireotide long acting | Injection, pasireotide long acting, 1 mg | Precertification Notification | 1/1/2021 | Endocrine Disorders |
| J1602 | SIMPONI ARIA | golimumab | Golimumab for iv use 1mg | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J7402 | SINUVA | mometasone furoate | Mometasone furoate sinus implant, (sinuva), 10 micrograms | Precertification Notification | 1/1/2021 | Nasal Polyps |
| J2327 | Skyrizi | Risankizumab | Injection, risankizumab-rzaa, intravenous, 1 mg (SKYRIZI) | PA Request | 11/1/23 | Auto-inflammatory Conditions |
| J7331 | Sodium Hyaluronate | hyaluronan or derivative | Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg | No PA/No Precert Required | N/A | Osteoarthritis |
| J1300 | SOLIRIS | eculizumab | Injection, eculizumab, 10 mg | PA Request | 1/1/2022 | Auto-inflammatory Conditions |
| J1930 | SOMATULINE DEPOT | lanreotide | Injection, lanreotide, 1 mg | PA Request | 1/1/2023 | Endocrine Disorders |
| J2326 | SPINRAZA | Nusinersen | Injection, nusinersen, 0.1 mg | PA Request | 10/1/2022 | Spinal Muscular Atrophy |
| J3490 | SPRAVATO | esketamine nasal spray | Esketamine Nasal Spray, 28 mg | PA Request | 1/1/2023 | Antidepressants |
| J3358 | STELARA IV | Ustekinumab | Ustekinumab, for intravenous injection, 1 mg | PA Request | 10/1/2022 | Auto-inflammatory Conditions |
| J3357 | STELARA SC | Ustekinumab | Ustekinumab, for subcutaneous injection, 1 mg | PA Request | 10/1/2022 | Auto-inflammatory Conditions |
| J7321 | Supartz-FX | Hyaluronan or derivative | Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose | No PA/No Precert Required | N/A | Osteoarthritis |
| J9226 | SUPPRELIN LA | histrelin | Histrelin implant (supprelin la), 50 mg | Precertification Notification | 1/1/2021 | Metabolic Conditions |
| J1627 | SUSTOL | granisetron, extended-release | Injection, granisetron, extended-release, 0.1 mg | PA Request | 8/1/2022 | Anti-emetics |
| J2779 | Susvimo | Susvimo/ranibizumab | Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg | Precertification Notification | 5/1/23 | Ophthalmic Disorders |
| J2860 | SYLVANT | siltuximab | Injection, siltuximab, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| 90378 | SYNAGIS | respiratory syncytial virus, monoclonal antibody | Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each | Precertification Notification | 1/1/2021 | Passive Immunizing and Treatment Agents |
| J7331 | Synojoynt | Hyaluronan or derivative | Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg | No PA/No Precert Required | N/A | Osteoarthritis |
| J9262 | SYNRIBO | omacetaxine mepesuccinate | Injection, omacetaxine mepesuccinate, 0.01 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7325 | Synvisc | Hyaluronan or derivative | Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg | No PA/No Precert Required | N/A | Osteoarthritis |
| J7325 | Synvisc-One | Hyaluronan or derivative | Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg | No PA/No Precert Required | N/A | Osteoarthritis |
| J9171 | TAXOTERE | docetaxel | Injection, docetaxel, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9022 | TECENTRIQ | atezolizumab | Inj, atezolizumab,10 mg | PA Request | 1/1/2023 | Oncology |
| J9328 | TEMODAR | temozolomide | Injection, temozolomide, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9330 | TEMSIROLIMUS | temsirolimus | Injection, temsirolimus, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| Q2017 | TENIPOSIDE | teniposide | Injection, teniposide, 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9340 | TEPADINA | thiotepa | Injection, thiotepa, 15 mg | Precertification Notification | 1/1/2021 | Oncology |
| J3241 | TEPEZZA | teprotumumab-trbw | Injection, teprotumumab-trbw, 10 mg | PA Request | 8/1/2022 | Thyroid Eye Disease |
| J2356 | TEZSPIRE | tezepelumab-ekko | Tezepelumab-ekko, 1 mg | PA Request | 1/1/2023 | Asthma |
| J9340 | THIOTEPA | thiotepa | Injection, thiotepa, 15 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7197 | THROMBATE III | antithrombin III | Antithrombin III (human), per i.u. | Precertification Notification | 1/1/2021 | Hereditary Antithrombin Deficiency |
| 90586 | TICE BCG | bcg live | Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use | Precertification Notification | 1/1/2021 | Oncology/vaccine |
| J9030 | TICE BCG | bcg live | Bcg live intravesical instillation, 1 mg | Precertification Notification | 1/1/2021 | Oncology/vaccine |
| J9273 | TIVDAK | tisotumab vedotin-tftv | Injection, tisotumab vedotin-tftv, 1 mg | Not Covered | 7/1/2022 | Systemic Lupus Erythematosus (SLE) |
| J9181 | TOPOSAR | etoposide | Injection, etoposide, 10 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9351 | TOPOTECAN HCL | topotecan | Injection, topotecan, 0.1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9330 | TORISEL | temsirolimus | Injection, temsirolimus, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J1190 | TOTECT | dexrazoxane hcl | Injection, dexrazoxane hydrochloride, per 250 mg | Precertification Notification | 1/1/2021 | Chemotherapy Protectant |
| Q5116 | Trazimera | Trastuzumab-qyyp | Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg | No PA/No Precert Required | N/A | Oncology |
| J9033 | TREANDA | bendamustine hcl | Injection, bendamustine hcl (treanda), 1 mg | PA Request | 1/1/2023 | Oncology |
| J3315 | TRELSTAR | triptorelin pamoate | Inj Triptorelin Pamoate 3.75 mg (Trelstar) | PA Request | 1/1/2023 | Oncology |
| J1628 | TREMFYA | guselkumab | Inj., guselkumab, 1 mg | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| J3285 | TREPROSTINIL | treprostinil | Injection, treprostinil, 1 mg | Precertification Notification | 1/1/2021 | Cardiovascular Agents |
| J7181 | TRETTEN | factor xiii a-subunit | Injection, factor xiii a-subunit, (recombinant), per iu | Precertification Notification | 1/1/2021 | Hemophilia |
| J1443 | Triferic | Ferric Pyrophosphate Citrate | Injection, ferric pyrophosphate citrate solution (triferic), 0.1 mg of iron | No PA/No Precert Required | N/A | Anemia |
| J1444 | Triferic | Ferric Pyrophosphate Citrate | Injection, ferric pyrophosphate citrate powder, 0.1 mg of iron | No PA/No Precert Required | N/A | Anemia |
| J1445 | Triferic AVNU | Ferric Pyrophosphate Citrate | Injection, ferric pyrophosphate citrate solution (triferic avnu), 0.1 mg of iron | No PA/No Precert Required | N/A | Anemia |
| J7332 | TRILURON | Hyaluronan or derivative | Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg | PA Request | 10/1/2022 | Osteoarthritis |
| J3316 | TRIPTODUR | triptorelin | Inj., triptorelin xr 3.75 mg | PA Request | 1/1/2023 | Endocrine Disorders |
| J9017 | TRISENOX | arsenic trioxide | Injection, arsenic trioxide, 1 mg | Precertification Notification | 1/1/2021 | Oncology |
| J7329 | TRIVISC | Hyaluronan or derivative | Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg | PA Request | 10/1/2022 | Osteoarthritis |
| J9317 | TRODELVY | sacituzumab govitecan-hziy | Injection, Sacituzumab Govitecan-Hziy, 2.5 Mg | PA Request | 1/1/2023 | Oncology |
| J1746 | TROGARZO | ibalizumab-uiyk | Injection, ibalizumab-uiyk, 10 mg | PA Request | 5/1/2023 | HIV/AIDS |
| Q5115 | Truxima | Rituximab-abbs | Injection, rituximab-abbs, biosimilar, (truxima), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| J2323 | TYSABRI | Natalizumab | Injection, natalizumab, 1 mg | PA Request | 10/1/2022 | Multiple Sclerosis |
| J7686 | TYVASO | treprostinil | Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg | Precertification Notification | 1/1/2021 | Pulmonary Arterial Hypertension (PAH) |
| Q5111 | Udenyca | Pegfilgrastim-cbqv | Injection, pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg | No PA/No Precert Required | N/A | Neutropenia |
| J1303 | ULTOMIRIS | Ravulizumab | Injection, ravulizumab-cwvz, 10 mg | PA Request | 10/1/2022 | Auto-inflammatory Conditions |
| J1823 | UPLIZNA | inebilizumab-cdon | Inj. Inebilizumab-Cdon, 1 Mg | PA Request | 1/1/2023 | Auto-inflammatory Conditions |
| C9097and J2777 | VABYSMO | faricimab-svoa | Inj, faricimab-svoa, 0.1 mg | Not Covered | 7/1/2022 | Oncology |
| J9357 | VALRUBICIN | valrubicin | Injection, valrubicin, intravesical, 200 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9357 | VALSTAR | valrubicin | Injection, valrubicin, intravesical, 200 mg | Precertification Notification | 1/1/2021 | Oncology |
| J9225 | VANTAS | histrelin | Histrelin implant (vantas), 50 mg | Precertification Notification | 1/1/2021 | Oncology |
| J2797 | VARUBI | rolapitant | Injection, rolapitant, 0.5 mg | Precertification Notification | 1/1/2021 | Anti-emetics |
| J9303 | VECTIBIX | panitumumab | Injection, panitumumab, 10 mg | PA Request | 1/1/2023 | Oncology |
| Q5129 | Vegzelma | bevacizumab-adcd | Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg | No PA/No Precert Required |
