Medical Specialty Drug List - PA Required

HCPCS codes Brand name Generic name HCPCS Description Requirement Requirement effective date Clinical Category
J3262 Actemra tocilizumab INJECTION, TOCILIZUMAB, 1 MG PA Request 1/1/2023 Auto-inflammatory Conditions
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
J0172 ADUHELM aducanumab-avwa Injection, aducanumab-avwa, 2 mg Exclusion: Medical Necessity Review Required 1/1/2022 Antidementia Agent
J0220 Alglucosidase alfa Alglucosidase alfa Injection, alglucosidase alfa, 10 mg, not otherwise specified PA Request 10/1/2022 Enzyme Deficiency
J9057 Aliqopa copanlisib Inj., copanlisib, 1 mg PA Request 1/1/2023 Oncology
J0225  Amvuttra vutrisiran  Injection, vutrisiran, 1 mg  PA Request  11/1/2023  Amyloidosis
J9302 Arzerra ofatumumab INJECTION, OFATUMUMAB, 10 MG PA Request 1/1/2023 Oncology
J9035 AVASTIN bevacizumab Injection, bevacizumab, 10 mg PA Request 8/1/2022 Oncology
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
J9229 Besponsa inotuzumab ozogamicin Injection, inotuzumab ozogamicin, 0.1 mg PA Request 1/1/2023 Oncology
J9039 BLINCYTO blinatumomab Injection, blinatumomab, 1 microgram PA Request 1/1/2022 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 Neurotoxins
J1786 CEREZYME Imiglucerase Injection, imiglucerase, 10 units PA Request 10/1/2022 Enzyme Deficiency
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
J0584 Crysvita burosumab Injection, burosumab-twza 1 mg PA Request 1/1/2023 Metabolic Conditions
J9308 Cyramza ramucirumab Injection, ramucirumab, 5 mg PA Request 1/1/2023 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
J7318 DUROLANE Hyaluronan or derivative Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg PA Request 10/1/2022 Osteoarthritis
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
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
J3380 ENTYVIO Vedolizumab Injection, vedolizumab, 1 mg PA Request 10/1/2022 Auto-inflammatory Conditions
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)
J9055 Erbitux cetuximab Injection, Cetuximab, 10 Mg PA Request 1/1/2023 Oncology
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
J0178 EYLEA Aflibercept Injection, aflibercept, 1 mg PA Request 10/1/2022 Macular Degeneration
J0517 FASENRA benralizumab Injection, benralizumab, 1 mg PA Request 8/1/2022 Asthma
J9155 Firmagon degarelix INJECTION, DEGARELIX, 1 MG PA Request 1/1/2023 Oncology
J9307 FOLOTYN pralatrexate Injection, pralatrexate, 1 mg PA Request 1/1/2022 Oncology
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
J7320 GENVISC 850 Hyaluronan or derivative Hyaluronan or derivative, genvisc 850, for intra-articular injection, 1 mg PA Request 10/1/2022 Osteoarthritis
J9179 Halaven eribulin mesylate Injection, eribulin mesylate, 0.1 mg PA Request 1/1/2023 Oncology
J7170 HEMLIBRA Emicizumab Injection, emicizumab-kxwh, 0.5 mg PA Request 10/1/2022 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
J0135 HUMIRA adalimumab Injection, adalimumab, 20 mg PA Request 8/1/2022 Auto-inflammatory Conditions
J7322 HYMOVIS Hyaluronan or derivative Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg PA Request 10/1/2022 Osteoarthritis
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
J1745 INFLIXIMAB infliximab, excludes biosimilar Injection, infliximab, excludes biosimilar, 10 mg PA Request 8/1/2022 Auto-inflammatory Conditions
J1439 INJECTAFER Ferric carboxymaltose Injection, ferric carboxymaltose, 1 mg PA Request 10/1/2022 Anemia
J9354 Kadcyla ado-trastuzumab emtansine Injection, ado-trastuzumab emtansine, 1 mg PA Request 1/1/2023 Oncology
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
J9274 KIMMTRAK tebentafusp-tebn Inj, tebentafusp-tebn, 1 mcg PA Request 1/1/2023 Oncology
J2507 Krystexxa pegloticase Injection, pegloticase, 1 mg PA Request 1/1/2023 Auto-inflammatory Conditions
J9047 Kyprolis carfilzomib Injection, carfilzomib, 1 mg PA Request 1/1/2023 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
J9119 Libtayo cemiplimab-rwlc Inj., cemiplimab-rwlc, 1 mg PA Request 1/1/2023 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
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 leuoprolide acetate depot Injection, leuprolide acetate (for depot suspension), per 3.75 mg PA Request 1/1/2023 Oncology
J2503 MACUGEN Pegaptanib Injection, pegaptanib sodium, 0.3 mg PA Request 10/1/2022 Macular Degeneration
J9349 Monjuvi tafasitamab-cxix Inj., tafasitamab-cxix PA Request 1/1/2023 Oncology
J1437 MONOFERRIC Ferric derisomaltose Injection, ferric derisomaltose, 10 mg PA Request 10/1/2022 Anemia
J7327 MONOVISC Hyaluronan or derivative Hyaluronan or derivative, monovisc, for intra-articular injection, per dose PA Request 10/1/2022 Osteoarthritis
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
J1458 Naglazyme galsulfase Injection, galsulfase, 1 mg PA Request 1/1/2023 Enzyme Deficiency
J2506 NEULASTA pegfilgrastim, excludes biosimilar Injection, pegfilgrastim, excludes biosimilar, 0.5 mg PA Request 8/1/2022 Neutropenia
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
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
J2350 OCREVUS Ocrelizumab Injection, ocrelizumab, 1 mg PA Request 10/1/2022 Multiple Sclerosis
J0222 ONPATTRO patisiran Injection, patisiran, 0.1 mg PA Request 5/1/2023 Amyloidosis
J9299 OPDIVO nivolumab Injection, nivolumab, 1 mg PA Request 8/1/2022 Oncology
J9298  Opdualag  nivolumab and relatlimab-rmbw  Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg  PA Request  11/1/2023  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
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
J9204 Poteligeo mogamulizumab-kpkc Inj, mogamulizumab-kpkc, 1 mg PA Request 1/1/2023 Oncology
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)
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
J0896 Reblozyl luspatercept-aamt Inj luspatercept-aamt 0.25mg PA Request 1/1/2023 Myelodysplastic Syndrome
J1745 REMICADE infliximab, excludes biosimilar Injection, infliximab, excludes biosimilar, 10 mg PA Request 8/1/2022 Auto-inflammatory Conditions
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
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
J9227 SARCLISA isatuximab-irfc Injection, isatuximab-irfc, 10 mg PA Request 5/1/2023 Oncology
J1602 Simponi Aria golimumab Golimumab for iv use 1mg PA Request 1/1/2023 Auto-inflammatory Conditions
 J2327 Skyrizi  risankizumab-rzaa  Injection, risankizumab-rzaa, intravenous, 1 mg  PA Request  11/1/2023  Auto-inflammatory Conditions 
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
J1627 SUSTOL granisetron, extended-release Injection, granisetron, extended-release, 0.1 mg PA Request 8/1/2022 Anti-emetics
J9022 Tecentriq atezolizumab Inj, atezolizumab,10 mg PA Request 1/1/2023 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
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
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
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
J2323 TYSABRI Natalizumab Injection, natalizumab, 1 mg PA Request 10/1/2022 Multiple Sclerosis
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
J9303 Vectibix panitumumab Injection, panitumumab, 10 mg PA Request 1/1/2023 Oncology
J9041 Velcade bortezomib Injection, bortezomib (velcade), 0.1 mg PA Request 1/1/2023 Oncology
J3396 Visudyne verteporfin Injection, Verteporfin, 0.1 Mg PA Request 1/1/2023 Ophthalmic Disorders
J3385 VPRIV Velaglucerase Alfa Injection, velaglucerase alfa, 100 units PA Request 10/1/2022 Enzyme Deficiency
J3032 VYEPTI Eptinezumab Injection, eptinezumab-jjmr, 1 mg PA Request 10/1/2022 Migraine
J0588 XEOMIN incobotulinumtoxin a Injection, incobotulinumtoxin a, 1 unit PA Request 6/1/2022 Neurotoxins
J0897 XGEVA denosumab Injection, denosumab, 1 mg PA Request 8/1/2022 Osteoporosis
J0775 Xiaflex collagenase, clostridium histolyticum INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG PA Request 1/1/2023 Enzyme
J2357 Xolair omalizumab Injection, omalizumab, 5 mg PA Request 8/1/2022 Asthma
J9228 Yervoy ipilimumab Injection, ipilimumab, 1 mg PA Request 1/1/2023 Oncology
J9223 Zepzelca lurbinectedin Inj. Lurbinectedin, 0.1 Mg PA Request 1/1/2023 Oncology
J0565 ZINPLAVA bezlotoxumab Injection, bezlotoxumab, 10 mg PA Request 8/1/2022 Passive Immunizing and Treatment Agents
Additional resources
Specialty drug list
SmartHealth Medical Benefit Specialty Medication Formulary
Medical Benefit Specialty Medication Formulary
Specialty Drug list
SmartHealth Medical Specialty Drug List - No PA Required

Medical Specialty Drug List No PA Required