Medicare PA List & Medicare Part B Drug List - Effective 1/1/2023
Date: 11/30/22
Medicare Prior Authorization
List effective 1/1/2023
Wellcare requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare.
Wellcare is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO
Effective January 1st, 2023, the following are changes to prior authorization requirements:
Service Category | PA Rule | Services | Procedure Codes |
|---|---|---|---|
Anesthesia
| No PA Required | Anesthesia for nerve blocks | 01991, 01992 |
Audiology | PA Required | Hearing aid | V5256, V5258, V5261 |
No PA Required | Speech audiometry threshold | 0210T | |
Behavioral Health | PA Required | Behavior assessments | 97151, 97152 |
Adaptive behavior treatment | 97153, 97154, 97155, 97156 | ||
No PA Required
| Psychotherapy, training & education | 90832, 90834, 90837, 90846, 90847, 90853, G0177 | |
Hypnotherapy | 90880 | ||
Brief behavior assessment | 96127 | ||
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|
|
|
Behavioral Health | PA Required | Behavior assessments | 97151, 97152 |
Adaptive behavior treatment | 97153, 97154, 97155, 97156 | ||
No PA Required
| Psychotherapy, training & education | 90832, 90834, 90837, 90846, 90847, 90853, G0177 | |
Hypnotherapy | 90880 | ||
Brief behavior assessment | 96127 | ||
Breast reconstruction | PA Required except with breast cancer diagnosis | Breast reconstruction | 19367, 19368, 19369 |
Cardiovascular | PA Required | Artificial heart | 33927 |
Pulmonary artery pressure sensor | C2624 | ||
Unlisted procedures | 37501 | ||
No PA Required | Operative ablation | 33261 | |
Exclusion left atrial appendage | 33267, 33268, 33269 | ||
Artificial heart removal/replacement | 33928, 33929 | ||
Extracorporeal membrane oxygenation (ECMO) | 33953, 33954, 33955, 33956, 33957, 33958, 33959 | ||
External circulatory support | 92971, G0166 | ||
Carotid intima media thickness study | 93895 | ||
Carotid sinus baroreflex activation device | 0269T | ||
Devices and monitoring | 0497T, 0498T, 0650T | ||
Blinded procedure for NYHA Class III/IV heart failure | C9758 | ||
Cochlear and other auditory implants | PA Required | Auditory implant and device | L8619, L8690, L8691 |
No PA Required | Replacement Headset/headpiece | L8615 | |
|
|
|
|
Cosmetic and reconstructive | PA Required | Lipectomy | 15876, 15878 |
Reconstruction head/face | 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275 | ||
Excision or surgical planing for rhinophyma | 30120 | ||
No PA Required | Reduction forehead | 21137, 21138, 21139 | |
Otoplasty | 69300 | ||
Dental | No PA Required | Application of topical fluoride varnish | 99188 |
Dermatology | PA Required | Chemodenervation of eccrine glands | 64650, 64653 |
No PA Required | Autografts | 15131, 15135, 15136, 15150, 15152, 15155, 15156, 15157 | |
Laser treatments | 17106, 0491T, 0492T | ||
Cryotherapy | 17340 | ||
Incision and drainage, deep abscess | 22010, 22015 | ||
Cell therapy for scleroderma | 0489T, 0490T | ||
Autologous platelet rich plasma | G0465 | ||
Diagnostic imaging | PA Required | Magnetic resonance image guided high intensity focused ultrasound | 0398T |
No PA Required | Ablation, cryosurgical, of fibroadenoma | 19105 | |
Discography | 72285, 72295 | ||
Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac) | 76979 | ||
Fluoroscopic guidance | 77002, 77003 | ||
Unlisted imaging procedures | 78199, 78399, 75899, 78799 | ||
Salivary gland imaging and function study | 78230, 78231, 78232 | ||
Gastrointestinal system imaging | 78261, 78282, 78299 | ||
Nervous system imaging | 78610, 78635, 78660, 78699 | ||
CAD for lesion detection | 0174T, 0175T | ||
Myocardial imaging | 0331T, 0332T | ||
Radiostereometric analysis (RSA) | 0348T, 0349T, 0350T | ||
Optical coherence tomography (OCT) | 0351T, 0352T, 0353T, 0354T, 0443T, 0485T, 0486T, 0606T | ||
Biomechanical mapping | 0487T | ||
Spectroscopy studies | 0493T, 0641T, 0642T, 0658T | ||
Cardiac magnetic resonance imaging for morphology and function | C9762, C9763 | ||
Set-up portable x-ray equipment | Q0092 | ||
DME & Supplies | PA Required | Walker, heavy-duty | E0147 |
Hospital beds and accessories | E0181, E0184, E0185, E0186, E0193, E0196, E0197, E0199, E0250, E0251, E0255, E0256, E0260, E0261, E0271, E0272, E0277, E0280, E0293, E0294, E0295, E0301, E0303, E0304, E0305, E0310, E0329, E0371, E0373 | ||
Respiratory devices | E0434, E0439, E0445, E0465, E0466, E0470, E0471, E0482, E0483, E0486, E1390, E1399 | ||
Patient lifts | E0630, E0635, E0636, E0640 | ||
Pneumatic compressor devices | E0650, E0651, E0652, E0656, E0660, E0667, E0668, E0671, E0673, E0675, E0676 | ||
Nerve stimulators | E0720, E0730, E0731, E0740, E0745, E0747, E0748, E0760, E0766 | ||
Diabetic devices & supplies | E0784, K0554 | ||
Continuous passive motion device | E0935 | ||
Wheelchairs, power operated vehicles, and accessories | E0953, E0954, E0956, E0957, E0973, E0981, E0982, E0990, E1002, E1007, E1008, E1010, E1016, E1028, E1031, E1035, E1038, E1050, E1060, E1088, E1150, E1161, E1195, E1226, E1230, E1236, E1238, E1240, E2209, E2210, E2228, E2300, E2310, E2312, E2313, E2322, E2325, E2330, E2331, E2359, E2361, E2363, E2365, E2366, E2367, E2370, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2626, E2627, K0003, K0004, K0005, K0006, K0007, K0010, K0017, K0018, K0019, K0037, K0042, K0043, K0044, K0045, K0047, K0051, K0052, K0053, K0069, K0070, K0071, K0072, K0077, K0108, K0195, K0733, K0739, K0800, K0801, K0806, K0808, K0813, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0835, K0836, K0837, K0838, K0839, K0841, K0842, K0843, K0848, K0849, K0856, K0857, K0858, K0859, K0861, K0862, K0863 | ||
Upper & lower limb bracing devices | E1800, E1801, E1805, E1810, E1811, E1815, E1825 | ||
Speech generating device/accessory | E2508, E2510, E2512 | ||
No PA Required | Skin protection supplies | E0188, E0190, E0191, A4640 | |
Pump or water circulating pad | E0236 | ||
Respiratory equipment | E0550, E0555, E0560, E0565, E0600, E0615, E0621, E0700, E0781, E0791, K0730 | ||
Traction equipment, trapeze bars, extremity belt/harness | E0849, E0855, E0870, E0910, E0911, E0912, E0940, E0945 | ||
Wheelchairs and accessories | E0950, E0951, E0952, E0955, E0960, E0978, E0995, E1020, E2202, E2203, E2204, E2311, E2321, E2323, E2326, E2342, E2601, E2602, E2611, E2612, E2619, K0002, K0038, K0039, K0040, K0041, K0056, K0073 | ||
Infusion pumps and supplies | A4220, A4222, A4602, B9004, K0455, K0552, K0553, K0603 | ||
Helmet | A8003 | ||
Miscellaneous DME supplies | A4465, A5102, A7048, A9999 | ||
Surgical supplies | C1761, C1823, L8612, L8684 | ||
Endocrinology | PA Required | Unlisted laparoscopy procedure | 60659 |
No PA Required | Ambulatory continuous glucose monitoring | 95250 | |
Creation of subcutaneous pocket/removal implantable interstitial glucose sensor | 0446T, 0447T, 0448T | ||
Enteral & Parenteral nutrition | PA Required | In-line cartridge digestive enzyme | B4105 |
No PA Required | Nutrition | B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4160, B4161, B4185 | |
Home therapy | S9340, S9341, S9342, S9343 | ||
Gastroenterology | PA Required | Unlisted laparoscopy, spleen | 38129 |
Transoral lower esophageal myotomy | 43497 | ||
No PA Required | Esophagogastroduodenoscopy | 43235, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43245, 43247, 43248, 43249, 43250, 43251, 43253, 43254, 43255, 43259 | |
Gastric/gastrointestinal systems surgery/procedures | 43651, 43652, 43882, 44139, 44899, 45499, 47570, 0184T | ||
General surgery | No PA Required | Hernia repair | 49495, 49496, 49505, 49525, 49550, 49570, 49585, 49650, 49651 |
Adrenalectomy | 60545 | ||
Genetic counseling | No PA Required | Genetic counseling services | 96040 |
Gynecology | No PA Required | Vulvectomy | 56632, 56637, 56640 |
Stress incontinence treatment, revision/removal of vaginal graft | 57288, 57289, 57296 | ||
Hysteroscopy | 58558, 58565, 58579 | ||
Laparoscopy | 58672, 58673, 58674, 58679 | ||
Resection initial/tumor debulking | 58950, 58958 | ||
Hysterectomy after cesarean | 59525 | ||
Uterine fibroids(s) ablation | 0404T | ||
Home care | No PA Required | Home visit | 99501, 99502, 99503, 99505, 99506, 99507, 99511 |
Infertility | PA Required | Artificial insemination | 58321, 58322, 58323, 58345 |
Embryo transfer | 58970, 58974, 58976 | ||
Infusion services | No PA Required | Infusion and home infusion therapy | 96371, 96422, 96425, 96440, 96549 S9346, S9348, S9364, S9366, S9367, S9494, S9500 |
Injectable medications | Step therapy | Injectables | J2777, J3299, Q2056, Q5124, Q5125 |
PA Required | Injectables | C9047, J0135, J0180, J0221, J0565, J0596, J0630, J0725, J0745, J1170, J1290, J1322, J1560, J1600, J1620, J1726, J1729, J1744, J1750, J1756, J1830, J2358, J2440, J2502, J2504, J3060, J3355, J7175, J7179, J7189, J7196, J7201, J7209, Q0138, Q0139, Q0221, Q2026 | |
No PA Required | Injectables
| 0481T, C9257, C9290, J0122, J0130, J0200, J0205, J0210, J0215, J0288, J0289, J0300, J0348, J0380, J0390, J0395, J0401, J0470, J0475, J0480, J0485, J0520, J0583, J0600, J0620, J0637, J0714, J0740, J0742, J0770, J0834, J0841, J0875, J0878, J0887, J0895, J1071, J1162, J1180, J1201, J1250, J1265, J1270, J1320, J1325, J1327, J1436, J1440, J1451, J1452, J1571, J1573, J1640, J1645, J1652, J1655, J1730, J1738, J1833, J1835, J1890, J1945, J1950, J1960, J1990, J2248, J2260, J2265, J2270, J2274, J2278, J2315, J2320, J2407, J2425, J2426, J2513, J2547, J2670, J2724, J2725, J2730, J2770, J2788, J2792, J2810, J2910, J2916, J2995, J3070, J3090, J3095, J3145, J3265, J3280, J3320, J3350, J3364, J3365, J3400, J7168, J7316, Q5105, S0020, S0028, S0030, S0032, S0073, S0077, S0078, S0164, S0171 | |
Laboratory | PA Required | DMD (Dystrophin) | 81161 |
Multianalyte assay tests | 0014M, 0017M | ||
Proprietary Laboratory Analysis (PLA) Codes | 0002U, 0003U, 0027U, 0037U, 0040U, 0062U, 0063U, 0092U, 0093U, 0105U, 0108U, 0112U, 0117U, 0163U, 0169U, 0170U, 0171U, 0174U, 0177U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0242U, 0243U, 0244U, 0245U, 0246U, 0247U, 0250U, 0254U, 0329U | ||
Quantitative drug testing | G0481, G0482, G0483 | ||
No PA Required | Drug tests | 80184, 80368, 83992, G0480, G0659 | |
Unlisted lab procedures | 81099, 85999, 86849, 87999, 88099, 88749, 89240 | ||
Human leukocyte antigen (HLA) Typing | 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86812, 86813, 86816, 86817, 86825, 86826 86828, 86829, 86830, 86831, 86832, 86833, 86834, 86835 | ||
Genetic and multianalyte assay tests | 81341, 81420, 81506, 81507, 82784, 87483, 88239, | ||
Proprietary Laboratory Analysis (PLA) Codes | 0140U, 0141U, 0142U, 0152U, 0206U, 0207U, 0210U, 0226U, 0251U, 0323U, 0330U, 0500T | ||
Medication | PA Required | Buprenorphine/naloxone | J0574 |
Dexamethasone, ophthalmic insert | J1096 | ||
Ganciclovir 4.5 mg long-acting implant | J7310 | ||
Lymphocyte immune globulin | J7511 | ||
Treprostinil inhalation solution | J7686 | ||
Iloprost inhalation solution | Q4074 | ||
Dextroamphetamine sulfate 5mg | S0160 | ||
No PA Required | Bupivacaine collagen-matrix implant 1 mg | C9089 | |
Cinacalcet oral 1mg for (ESRD on dialysis) | J0604 | ||
Phenylephrine & Ketorolac Ophthalmic | J1097 | ||
Insulin for administration through DME | J1817 | ||
Topical for actinic keratosis | J7308, J7309 | ||
Capsaicin patch | J7335, J7336 | ||
Parenteral solutions | J7501, J7503, J7505, J7508, J7516, J7518, J7520, J7525, J7599 | ||
Inhalation solutions | J2062, J7604, J7622, J7624, J7627, J7628, J7629, J7632, J7633, J7634, J7635, J7636, J7640, J7641, J7647, J7648, J7649, J7650, J7658, J7659, J7660, J7667, J7668, J7669, J7670, J7680, J7681, J7683, J7684, J7685, J7699 | ||
Non-inhalation drug for DME | J7799 | ||
Unlisted chemo drug | J7999 | ||
Antiemetics | J8498, J8597, Q0167, Q0174, S0183 | ||
Leuprolide acetate per 1mg | J9218 | ||
Drug or biological, part b drug competitive acquisition program (CAP) | Q4082 | ||
Drugs for opioid use disorder | S0106, S0109 | ||
Calcitrol | S0169 | ||
Neonatal care | PA Required | Unlisted fetal invasive procedure | 59897 |
No PA Required | Initiation of hypothermia in neonate | 99184 | |
Neurology | PA Required | Creation of lesion by stereotactic method | 61790, 61791 |
No PA Required | Graft for facial nerve paralysis | 15840, 15841, 15842, 15845 | |
Injection for myelogram/CT | 62284, 62294 | ||
Removal of implanted catheter | 62355 | ||
Quantitative sensory testing (QST) | 0106T, 0107T, 0108T, 0109T, 0110T | ||
Neurostimulators | PA Required | Insertion/replacement neurostimulator | 0425T, 0426T |
No PA Required | Electronic analysis of neurostimulator | 95970, 95971, 95972, 95980, 95981, 95982 | |
Removal of neurostimulators system | 0428T | ||
Nutritional counseling | No PA Required | Nutritional counseling, dietitian visit | S9470 |
Ophthalmology | PA Required | Prosthetic eye, scleral cover shell | V2623, V2627, V2629 |
No PA Required | Keratoplasty, keratoprosthesis | 65730, 65750, 65755, 65756, 65757, 65770 | |
Glaucoma treatments | 65855, 66170, 66172, 66183 | ||
Cataract procedures | 66820, 66821, 66825, 66830, 66840, 66850, 66852, 66940, 66982, 66983, 66984, 66985, 66986, 66987, 66988, 66989, 66991 | ||
Treatment of extensive/progressive retinopathy, scleral reinforcement | 67228, 67255 | ||
Unlisted ophthalmology procedure | 67399, 92499 | ||
Orbitotomy without bone flap | 67405 | ||
Canthotomy | 67715 | ||
Eyelid procedures | 67912, 67938, 67961, 67966, 67999 | ||
Conjunctiva procedures | 68325, 68340, 68360, 68371, 68399 | ||
Lacrimal procedures | 68761, 68899 | ||
Retinal prosthesis | 0100T | ||
Ocular monitoring and screening | 0198T, 0329T, 0330T, 0333T, 0378T, 0379T | ||
Scleral lenses | V2531 | ||
Orthopedic | PA Required | Computer-assisted surgical navigation | 0054T, 0055T |
No PA Required | Procedures upper extremities | 23450, 23462, 23465, 23490, 24346, 25240, 25449, 25830, 26497, 26530, 26531, 26535, 26536 | |
Open treatment of iliac spine(s) | 27215 | ||
Procedures lower extremities | 27330, 27455, 27457, 27538, 27540, 27830, 28302, 28302, 28510, 28705, 28715, 28725, 28730, 28735, 28737, 28740 | ||
Arthroscopy | 29800, 29830, 29835, 29847, 29900, 29902, 29904, 29905, 29906 | ||
Device placement for radiostereometric analysis | 0347T | ||
SI Joint injection | G0259 | ||
Orthotics and Prosthetics | PA Required | Prosthesis (penile) | C1813, C2622 |
Spinal orthotics
| L0456, L0457, L0462, L0464, L0482, L0486, L0491, L0631, L0636, L0637, L0648, L0650, L0999, L1005, L1499 | ||
Lower extremity orthotics | L1685, L1686, L1832, L1833, L1834, L1843, L1844, L1845, L1846, L1907, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1990, L2020, L2036, L2037, L2108, L2250, L2280, L2330, L2340, L2350, L2510, L2520, L2861, L2999, L3030, L3230, L3730, L3763, L3901, L3999, L4631 | ||
Lower extremity prosthetics | L5000, L5020, L5050, L5100, L5210, L5220, L5301, L5312, L5321, L5331, L5530, L5540, L5580, L5590, L5611, L5617, L5626, L5631, L5643, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5665, L5671, L5673, L5677, L5679, L5681, L5683, L5700, L5701, L5703, L5704, L5705, L5706, L5707, L5781, L5782, L5785, L5790, L5811, L5812, L5814, L5816, L5822, L5828, L5840, L5845, L5848, L5856, L5857, L5920, L5940, L5950, L5960, L5961, L5962, L5964, L5968, L5973, L5975, L5976, L5979, L5980, L5981, L5984, L5986, L5987, L5988, L5999 | ||
Upper extremity prosthetics
| L6055, L6100, L6110, L6120, L6500, L6550, L6621, L6624, L6686, L6687, L6689, L6693, L6694, L6695, L6696, L6698, L6708, L6709, L6721, L6722, L6880, L6881, L6882, L6884, L6935, L6955, L7007, L7009, L7040, L7180, L7404, L7499, L8699, L8701, L9900 | ||
No PA Required | Impression and prosthetic preparation | 21076, 21079, 21080, 21081, 21082, 21083, 21085 | |
Cervical collar | L0200 | ||
Orthotics | L0460, L0635, L1848, L2112, L2114, L2116, L3760, L3905, L3915, L3916, L3960, L4205, L5450, L5460 | ||
Battery charger(s) | L7366, L7368 | ||
Custom breast prosthesis | L8035 | ||
Artificial larynx | L8500 | ||
Ocular implant | L8610, L8670 | ||
Osteopathy | No PA Required | Osteopathic manipulative treatment | 98925, 98926, 98927, 98928, 98929 |
Otolaryngology | No PA Required | Surgical procedures of nasal/sinus and ears | 31050, 31051, 31075, 31080, 31081, 31084, 31086, 31087, 31090, 31201, 31290, 31291, 31294, 31611, 69717, 69979 |
Pain management | PA Required | Injection, anesthetic agent or steroid | 64400, 64408, 64415, 64416, 64417, 64418, 64420, 64421, 64430, 64445, 64446, 64447, 64448, 64449, 64454, 64480, 64484, 64491, 64492, 64494, 64495 |
Implant of hypoglossal neurostimulator | 64582 | ||
Destruction by neurolytic agent | 64634, 64636, 64640 | ||
No PA Required | Injection, anesthetic agent | 64505, 64517, 64530 | |
Destruction by neurolytic agent | 64620, 64630, 64632, 64680, 64681 | ||
Preventive | No PA Required | Unlisted preventative medicine service | 99429, 0358T |
Preventive behavior change program | 0403T, 0488T | ||
Professional services | No PA Required | Physician or other qualified health care professional supervision | 99380, G0068, G0128, G2082, G0039 |
Pulmonology | PA Required | Drug Induced Sleep Endoscopy (DISE) | 42975 |
No PA Required | Bronchoscopy | C9751 | |
Skin substitute | PA Required | Skin substitute products | Q4107, Q4108, Q4114, Q4123, Q4127, Q4130, Q4140, Q4141, Q4142, Q4143, Q4146, Q4147, Q4149, Q4150, Q4152, Q4156, Q4157, Q4164, Q4173, Q4175, Q4184, Q4185, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4198, Q4200, Q4201, Q4202, Q4203, Q4204, Q4249, Q4250, Q4254, Q4255, Q4112, Q4113 |
No PA Required | Dermal and epidermal substitute | J7340 | |
Therapy service | PA Required | Activity therapy | G0176 |
No PA Required | Extracorporeal shock wave | 0101T, 0102T | |
Transplant services | No PA Required | Surgical preparation | 0494T, 0495T, 0496T |
Transportation | No PA Required | Ambulance services | A0426, A0428, A0431, A0436, A0999 |
Unlisted misc. procedures | PA Required | Unlisted procedure mediastinum, diaphragm, mouth | 39499, 39599, 40899 |
No PA Required | Unlisted procedure, immunology | 95199 | |
Urology | PA Required | Unlisted laparoscopy, renal | 50549 |
No PA Required
| Lithotripsy, extracorporeal shock wave | 50590 | |
Closure of vesicouterine fistula | 51925 | ||
Cystourethroscopy | 52005, 52007, 52204, 52224, 52234, 52235, 52240, 52276, 52287, 52300, 52320, 52325, 52330, 52332, 52341, 52344, 52351, 52352, 52353, 52354, 52356, 52402, C9740, C9761, C9769 | ||
Insertion of tandem cuff | 53444 | ||
Transurethral radiofrequency micro-remodeling of female bladder neck and proximal | 53860 | ||
Destruction of penial lesion(s) | 54060 | ||
Unlisted laparoscopy, testis | 54699 | ||
Biopsy, prostate; needle or punch | 55700 | ||
Vaccines | No PA Required | Immunizations/administration SARS-CoV-2 | 90376, 90620, 91311, 0112A |
Appendix A
Medicare Part B Drug List
Effective 1/1/2023
Part B Drugs List Effective January 1, 2023
PROCEDURE | DESCRIPTION | STEP THERAPY |
|---|---|---|
892 | SPECIAL PROCESSED DRUGS - FDA APPROVED GENE THERAPY |
|
A9513 | LUTETIUM LU 177 DOTATATE THERAPEUTIC 1 MCI | STEP THERAPY |
C9065 | INJECTION ROMIDEPSIN NON-LYPOHILIZED 1MG |
|
C9074 | INJECTION LUMASIRAN 0.5 MG |
|
C9076 | LISOCABTAGENE MARALEUCEL PER THERAPEUTIC DOSE | STEP THERAPY |
C9096 | INJECTION, FILGARASTIM-AYOW, BIOSIMILAR, (RELEUKO), 1 MCG | NEW STEP THERAPY 2023 JANUARY |
C9097 | INJECTION, FARICIMAB-SVOA, 0.1 MG | NEW STEP THERAPY 2023 JANUARY |
C9399 | UNCLASSIFIED DRUGS OR BIOLOGICALS |
|
J0129 | ABATACEPT INJECTION | STEP THERAPY |
J0135 | INJECTION, ADALIMUMAB, 20 MG |
|
J0178 | AFLIBERCEPT INJECTION | STEP THERAPY |
J0179 | INJECTION BROLUCIZUMAB-DBLL 1 MG | STEP THERAPY |
J0180 | INJECTION, AGALSIDASE BETA, 1 MG |
|
J0202 | INJECTION ALEMTUZUMAB 1 MG |
|
J0220 | ALGLUCOSIDASE ALFA INJECTION |
|
J0221 | LUMIZYME INJECTION |
|
J0222 | INJECTION PATISIRAN 0.1 MG |
|
J0223 | INJECTION GIVOSIRAN 0.5 MG |
|
J0256 | ALPHA 1 PROTEINASE INHIBITOR |
|
J0257 | GLASSIA INJECTION |
|
J0364 | INJECTION APOMORPHINE HYDROCHLORIDE 1 MG |
|
J0490 | BELIMUMAB INJECTION |
|
J0517 | INJECTION BENRALIZUMAB 1 MG |
|
J0567 | INJECTION CERLIPONASE ALFA 1 MG |
|
J0570 | BUPRENORPHINE IMPLANT 74.2MG |
|
J0584 | INJECTION BUROSUMAB-TWZA 1 MG |
|
J0585 | INJECTION, ONABOTULINUMTOXINA | STEP THERAPY |
J0586 | ABOBOTULINUMTOXINA |
|
J0587 | INJ, RIMABOTULINUMTOXINB |
|
J0588 | INCOBOTULINUMTOXIN A |
|
J0591 | INJECTION DEOXYCHOLIC ACID 1 MG |
|
J0593 | INJECTION LANADELUMAB-FLYO 1 MG |
|
J0598 | C-1 ESTERASE, CINRYZE |
|
J0599 | INJECTION C-1 ESTERASE INHIBITOR 10 UNITS |
|
J0606 | INJECTION ETELCALCETIDE 0.1 MG |
|
J0630 | INJECTION, CALCITONIN SALMON, UP TO 400 UNITS |
|
J0638 | CANAKINUMAB INJECTION |
|
J0641 | INJECTION LEVOLEUCOVORIN NOS 0.5 MG |
|
J0642 | INJECTION LEVOLEUCOVORIN (KHAPZORY), 0.5 MG |
|
J0717 | CERTOLIZUMAB PEGOL INJ 1MG | STEP THERAPY |
J0718 | CERTOLIZUMAB PEGOL INJ | STEP THERAPY |
J0775 | COLLAGENASE, CLOST HIST INJ |
|
J0791 | INJECTION CRIZANLIZUMAB-TMCA 5 MG |
|
J0800 | INJECTION, CORTICOTROPIN, UP TO 40 UNITS | STEP THERAPY |
J0881 | INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) | STEP THERAPY |
J0882 | INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS) | STEP THERAPY |
J0885 | INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS | STEP THERAPY |
J0888 | EPOETIN BETA NON ESRD |
|
J0894 | INJECTION DECITABINE 1 MG |
|
J0896 | INJECTION LUSPATERCEPT-AAMT 0.25 MG | STEP THERAPY |
J0897 | DENOSUMAB INJECTION | STEP THERAPY |
J1190 | INJECTION, DEXRAZOXANE HCL, PER 250 MG |
|
J1300 | ECULIZUMAB INJECTION | STEP THERAPY |
J1301 | INJECTION EDARAVONE 1 MG |
|
J1303 | INJECTION RAVULIZUMAB-CWVZ 10 MG |
|
J1324 | ENFUVIRTIDE INJECTION |
|
J1427 | INJECTION VILTOLARSEN 10 MG |
|
J1428 | INJECTION ETEPLIRSEN 10 MG |
|
J1429 | INJECTION GOLODIRSEN 10 MG |
|
J1437 | INJECTION FERRIC DERISOMALTOSE 10 MG |
|
J1438 | INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG AD) |
|
J1439 | INJ FERRIC CARBOXYMALTOS 1MG |
|
J1442 | INJ FILGRASTIM EXCL BIOSIMIL | STEP THERAPY |
J1443 | INJ FERRIC PRPP CIT SOL 0.1 MG IRON |
|
J1447 | INJECTION TBO-FILGRASTIM 1 MICROG | STEP THERAPY |
J1458 | INJECTION GALSULFASE 1 MG |
|
J1459 | INJ IVIG PRIVIGEN 500 MG | STEP THERAPY |
J1554 | INJECTION IMMUNE GLOBULIN ASCENIV 500 MG | STEP THERAPY |
J1555 | INJECTION IMMUNE GLOBULIN 100 MG | STEP THERAPY |
J1556 | INJECTION IMM GLOB BIVIGAM, 500MG | STEP THERAPY |
J1557 | GAMMAPLEX INJECTION | STEP THERAPY |
J1558 | INJECTION IMMUNE GLOBULIN XEMBIFY 100 MG | STEP THERAPY |
J1559 | HIZENTRA INJECTION | STEP THERAPY |
J1561 | GAMUNEX-C/GAMMAKED | STEP THERAPY |
J1562 | INJECTION; IMMUNE GLOBULIN 10%, 5 GRAMS | STEP THERAPY |
J1566 | INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED | STEP THERAPY |
J1568 | OCTAGAM INJECTION | STEP THERAPY |
J1569 | GAMMAGARD LIQUID INJECTION | STEP THERAPY |
J1572 | FLEBOGAMMA INJECTION | STEP THERAPY |
J1575 | INJ IG/HYALURONIDASE 100 MG IG | STEP THERAPY |
J1599 | IVIG NON-LYOPHILIZED, NOS | STEP THERAPY |
J1602 | GOLIMUMAB FOR IV USE 1MG | STEP THERAPY |
J1628 | INJECTION GUSELKUMAB 1 MG |
|
J1632 | INJECTION BREXANOLONE 1 MG |
|
J1640 | INJECTION, HEMIN, 1 MG |
|
J1645 | INJECTION, DALTEPARIN SODIUM, PER 2500 IU |
|
J1675 | INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS |
|
J1743 | IDURSULFASE INJECTION |
|
J1744 | ICATIBANT INJECTION |
|
J1745 | INJ INFLIXIMAB EXCL BIOSIMILR 10 MG | STEP THERAPY |
J1746 | INJECTION IBALIZUMAB-UIYK 10 MG |
|
J1786 | IMUGLUCERASE INJECTION |
|
J1817 | INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS |
|
J1823 | INJECTION INEBILIZUMAB CDON 1 MG |
|
J1930 | INJECTION, PROPIOMAZINE, UP TO 20 MG |
|
J1931 | INJECTION, LARONIDASE, 0.1 MG |
|
J2170 | MECASERMIN INJECTION |
|
J2182 | INJECTION MEPOLIZUMAB 1MG |
|
J2212 | METHYLNALTREXONE INJECTION |
|
J2315 | INJECTION NALTREXONE DEPOT FORM 1 MG |
|
J2323 | NATALIZUMAB INJECTION | STEP THERAPY |
J2326 | INJECTION NUSINERSEN 0.1 MG |
|
J2350 | INJECTION OCRELIZUMAB 1 MG |
|
J2353 | INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG |
|
J2355 | INJECTION, OPRELVEKIN, 5 MG |
|
J2357 | INJECTION, OMALIZUMAB, 5 MG |
|
J2440 | INJECTION, PAPAVERINE HCL, UP TO 60 MG |
|
J2503 | INJECTION, PEGAPTANIB SODIUM, 0.3 MG | STEP THERAPY |
J2505 | INJECTION, PEGFILGRASTIM, 6 MG | STEP THERAPY |
J2507 | PEGLOTICASE INJECTION |
|
J2562 | PLERIXAFOR INJECTION |
|
J2777 | INJECTION, FARICIMAB-SVOA, 0.1 MG | NEW STEP THERAPY 2023 JANUARY |
J2778 | RANIBIZUMAB INJECTION | STEP THERAPY |
J2779 | INJECTION, RANIBIZUMAB, VIA INTRAVITREAL IMPLANT (SUSVIMO), 0.1 MG | NEW STEP THERAPY 2023 JANUARY |
J2783 | INJECTION, RASBURICASE, 0.5 MG |
|
J2786 | INJECTION RESLIZUMAB 1MG |
|
J2793 | RILONACEPT INJECTION |
|
J2796 | ROMIPLOSTIM INJECTION | STEP THERAPY |
J2797 | INJECTION ROLAPITANT 0.5 MG |
|
J2820 | INJECTION, SARGRAMOSTIM (CM-CSF), 50 MCG | STEP THERAPY |
J2840 | INJECTION SEBELIPASE ALFA 1 MG |
|
J2940 | INJECTION, SOMATREM, 1 MG |
|
J2941 | INJECTION, SOMATROPIN, 1 MG |
|
J3032 | INJECTION EPTINEZUMAB-JJMR 1 MG |
|
J3095 | TELEVANCIN INJECTION |
|
J3110 | INJECTION, TERIPARATIDE, 10 MCG |
|
J3111 | INJECTION ROMOSOZUMAB-AQQG 1 MG | STEP THERAPY |
J3140 | INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG |
|
J3240 | INJECTION, THYROTROPIN, UP TO 10 I.U. |
|
J3241 | INJECTION TEPROTUMUMAB-TRBW 10 MG | STEP THERAPY |
J3245 | INJECTION TILDRAKIZUMAB 1 MG |
|
J3262 | TOCILIZUMAB INJECTION | STEP THERAPY |
J3285 | INJECTION, TREPROSTINIL, 1 MG |
|
J3299 | TRIAMCINOLONE ACETONIDE (XIPERE), 1MG |
|
J3304 | INJECT TRIAMCINOLONE ACETONIDE PF ER MS F 1 MG | STEP THERAPY |
J3316 | INJECTION TRIPTORELIN EXTENDED-RELEASE 3.75 MG |
|
J3357 | USTEKINUMAB FOR SUBQ INJECTION 1 MG | STEP THERAPY |
J3358 | USTEKINUMAB, FOR INTRAVENOUS INJECTION, 1 MG |
|
J3380 | INJECTION VEDOLIZUMAB 1 MG | STEP THERAPY |
J3385 | VELAGLUCERASE ALFA |
|
J3396 | INJECTION, VERTEPORFIN, 0.1 MG | STEP THERAPY |
J3397 | INJECT VESTRONIDASE ALFA-VJBK 1 MG |
|
J3398 | INJECTION VORETIGENE NEPARVOVEC-RZYL 1 B VEC G |
|
J3399 | INJ AVSX-101-XIOI P-TX TO 5X10^15 VCTR GNOMS |
|
J3490 | UNCLASSIFIED DRUGS |
|
J3358 | USTEKINUMAB, FOR INTRAVENOUS INJECTION, 1 MG |
|
J3590 | UNCLASSIFIED BIOLOGICS |
|
J3591 | UNCLASS RX/BIOLOGICAL USED FOR ESRD ON DIALYSIS |
|
J7169 | INJ COAGULATION FACTOR XA INACTIVATED-ZHZO 10 MG |
|
J7170 | INJECTION EMICIZUMAB-KXWH 0.5 MG |
|
J7175 | INJ FACTOR X (HUMAN) 1IU |
|
J7177 | INJECTION HUMAN FIBRINOGEN CONCENTRATE 1 MG |
|
J7179 | VONVENDI INJ 1 IU VWF:RCO |
|
J7180 | FACTOR XIII ANTI-HEM FACTOR |
|
J7181 | FACTOR XIII RECOMB A-SUBUNIT |
|
J7182 | FACTOR VIII RECOMB NOVOEIGHT |
|
J7183 | WILATE INJECTION |
|
J7185 | XYNTHA INJ |
|
J7186 | ANTIHEMOPHILIC VIII/VWF COMP |
|
J7187 | INJECTION VON WILLEBRAND FACTOR COMPLEX HUMAN RISTOCETIN COFACTOR PER IV |
|
J7188 | INJECTION FACTOR VIII PER I.U. |
|
J7189 | FACTOR VIIA ANTIHEMOPHILIC FCT NOVOSEVEN RT1 MCG |
|
J7190 | FACTOR VIII, (ANTI-HEMOPHILIC FACTOR (HUMAN)), PER I.U. |
|
J7191 | FACTOR VIII (PORCINE) |
|
J7192 | FACTOR VIII RECOMBINANT NOS |
|
J7193 | FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U. |
|
J7194 | FACTOR IX, COMPLEX, PER I.U. |
|
J7195 | FACTOR IX RECOMBINANT NOS |
|
J7196 | ANTITHROMBIN RECOMBINANT |
|
J7197 | ANTITHROMBIN III (HUMAN), PER I.U. |
|
J7198 | ANTI-INHIBITOR, PER I.U. |
|
J7199 | HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED |
|
J7200 | FACTOR IX RECOMBINAN RIXUBIS |
|
J7201 | INJ FACTOR IX FC FUS PROTEIN PER IU |
|
J7202 | FACTOR IX IDELVION INJ |
|
J7203 | INJECTION FACTOR IX GLYCOPEGYLATED 1 IU |
|
J7204 | INJ FAC VIII ANTIHEM FAC GLYCOPEGYLATD-EXEI P-IU |
|
J7207 | FACTOR VIII PEGYLATED RECOMB |
|
J7208 | INJECTION FACTOR VIII PEGYLATED-AUCL 1 IU |
|
J7209 | FACTOR VIII NUWIQ RECOMB 1IU |
|
J7212 | FACTOR VIIA JNCW 1 MCG |
|
J7311 | INJECTION FA INTRAVITREAL IMPL 0.01 MG | STEP THERAPY |
J7312 | DEXAMETHASONE INTRA IMPLANT | STEP THERAPY |
J7313 | INJECTION FA INTRAVITREAL IMPL 0.01 MG | STEP THERAPY |
J7314 | INJECTION FA INTRAVITREAL IMPL 0.01 MG | STEP THERAPY |
J7318 | HYALURONAN/DERIVATIVE DUROLANE FOR IA INJ 1 MG | STEP THERAPY |
J7320 | HYALURONAN/DERIVITIVE GENVISC 850 IA INJ 1 MG | STEP THERAPY |
J7321 | HYALURONAN/DERIV HYALGAN/SUPARTZ IA INJ PER DOSE | STEP THERAPY |
J7322 | HYALURONAN/DRIV HYMOVIS IA INJ 1 MG | STEP THERAPY |
J7323 | EUFLEXXA INJ PER DOSE | STEP THERAPY |
J7324 | ORTHOVISC INJ PER DOSE | STEP THERAPY |
J7325 | SYNVISC OR SYNVISC-ONE | STEP THERAPY |
J7326 | GEL-ONE | STEP THERAPY |
J7327 | MONOVISC INJ PER DOSE | STEP THERAPY |
J7328 | HYAL/DERIV GELSYN-3 IA INJ 0.1 MG | STEP THERAPY |
J7329 | HYALURONAN/DERIVATIVE TRIVISC FOR IA INJ 1 MG | STEP THERAPY |
J7331 | HYALURONAN/DERIVATIVE SYNOJOYNT IA INJ 1 MG | STEP THERAPY |
J7332 | HYALURONAN/DERIVATIVE TRILURON IA INJ 1 MG | STEP THERAPY |
J7351 | INJECTION BIMATOPROST INTRACAMERAL IMPLANT 1 MCG |
|
J7352 | AFAMELANOTIDE IMPLANT 1 MG |
|
J7402 | MOMETASONE FUROATE SINUS IMPLANT SINUVA 10 MCG |
|
J7518 | MYCOPHENOLIC ACID, ORAL, 180 MG |
|
J7527 | ORAL EVEROLIMUS |
|
J7677 | REVEFENACIN INHAL SOL NONCOMPND ADM DME 1 MCG |
|
J7686 | TREPROSTINIL, NON-COMP UNIT |
|
J8650 | NABILONE ORAL |
|
J8705 | TOPOTECAN ORAL |
|
J8999 | NOS PRES DRUG, ORAL, CHEMO |
|
J9015 | ALDESLEUKIN/SINGLE USE VIAL |
|
J9017 | ARSENIC TRIOXIDE, 1MG |
|
J9019 | ERWINAZE INJECTION |
|
J9022 | INJECTION ATEZOLIZUMAB 10 MG | STEP THERAPY |
J9023 | INJECTION AVELUMAB 10 MG |
|
J9027 | INJECTION, CLOFARABINE, 1 MG |
|
J9034 | INJ. BENDEKA 1 MG |
|
J9035 | INJECTION, BEVACIZUMAB, 10 MG | STEP THERAPY (NOT REQUIRED FOR OPTHALMOLOGISTS) |
J9036 | INJECTION BENDAMUSTINE HYDROCHLORIDE 1 MG |
|
J9037 | INJECTION BELANTAMAB MAFODONTIN-BLMF 0.5 MG |
|
J9039 | INJECTION BLINATUMOMAB 1 MICROGRAM |
|
J9041 | INJECTION BORTEZOMIB 0.1 MG |
|
J9042 | BRENTUXIMAB VEDOTIN INJ | NEW STEP THERAPY 2023 JANUARY |
J9043 | CABAZITAXEL INJECTION |
|
J9044 | INJECTION BORTEZOMIB NOS 0.1 MG |
|
J9047 | INJECTION, CARFILZOMIB, 1 MG |
|
J9050 | CARMUSTINE, 100 MG |
|
J9055 | INJECTION, CETUXIMAB, 10 MG |
|
J9057 | INJECTION COPANLISIB 1 MG |
|
J9118 | INJECTION CALASPARGASE PEGOL-MKNL 10 UNITS |
|
J9119 | INJECTION CEMIPLIMAB-RWLC 1 MG | STEP THERAPY |
J9144 | INJECTION, DARATUMUMAB, 10 MG AND HYALURONIDASE-FIHJ | STEP THERAPY |
J9145 | INJECTION DARATUMUMAB 10 MG | STEP THERAPY |
J9153 | INJECTION LIPOSOMAL 1 MG DNR AND 2.27 MG CA |
|
J9173 | INJECTION DURVALUMAB 10 MG | STEP THERAPY |
J9176 | INJECTION ELOTUZUMAB 1MG | STEP THERAPY |
J9177 | INJECTION ENFORTUMAB VEDOTIN-EJFV 0.25 MG |
|
J9179 | ERIBULIN MESYLATE INJECTION |
|
J9198 | INJ GEMCITABINE HYDROCHLORIDE INFUGEM 100 MG |
|
J9203 | INJ GEMTUZUMAB OZOGAMICIN 0.1 MG |
|
J9204 | INJECTION MOGAMULIZUMAB-KPKC 1 MG |
|
J9205 | INJECTION IRINOTECAN LIPOSOME 1 MG |
|
J9210 | INJECTION, EMAPALUMAB-LZSG, 1MG | STEP THERAPY |
J9212 | INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG |
|
J9213 | INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS |
|
J9215 | INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU |
|
J9216 | INTERFERON, GAMMA 1-B, 3 MILLION UNITS |
|
J9223 | INJECTION LURBINECTEDIN 0.1 MG | STEP THERAPY |
J9225 | HISTRELIN IMPLANT, 50 MG |
|
J9226 | SUPPRELIN LA IMPLANT |
|
J9227 | INJECTION ISATUXIMAB-IRFC 10 MG |
|
J9228 | IPILIMUMAB INJECTION |
|
J9229 | INJECTION INOTUZUMAB OZOGAMICIN 0.1 MG |
|
J9246 | INJECTION MELPHALAN EVOMELA 1 MG |
|
J9261 | INJECTION NELARABINE 50 MG |
|
J9262 | INJECTION OMACETAXINE MEP, 0.01MG |
|
J9264 | INJECTION PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG |
|
J9266 | PEGASPARGASE/SINGL DOSE VIAL |
|
J9269 | INJECTION TAGRAXOFUSP-ERZS 10 MCG |
|
J9271 | INJECTION PEMBROLIZUMAB 1 MG | STEP THERAPY |
J9281 | MITOMYCIN PYELOCALYCEAL INSTILLATION 1 MG |
|
J9285 | INJECTION OLARATUMAB 10 MG |
|
J9299 | INJECTION NIVOLUMAB 1 MG | STEP THERAPY |
J9301 | OBINUTUZUMAB INJ |
|
J9303 | PANITUMUMAB INJECTION |
|
J9304 | INJECTION PEMETREXED PEMFEXY 10 MG |
|
J9305 | INJECTION PEMETREXED NOS10 MG |
|
J9306 | INJECTION, PERTUZUMAB, 1 MG |
|
J9308 | INJECTION RAMUCIRUMAB 5 MG | STEP THERAPY |
J9309 | INJECTION POLATUZUMAB VEDOTIN-PIIQ 1 MG | STEP THERAPY |
J9311 | INJECTION RITUXIMAB 10 MG AND HYALURONIDASE | STEP THERAPY |
J9312 | INJECTION RITUXIMAB 10 MG | STEP THERAPY |
J9313 | INJECTION MOXETUMOMAB PASUDOTOX-TDFK 0.01 MG |
|
J9316 | INJ PERTUZUMAB TRASTUZUMAB AND HYAL ZZXF PER 10 MG |
|
J9317 | INJECTION SACITUZUMAB GOVITECAN HZIY 2.5 MG |
|
J9325 | INJ TALIMOGENE LAHERPAREPVEC |
|
J9349 | INJECTION TAFASITAMAB-CXIX 2 MG |
|
J9352 | INJECTION TRABECTEDIN 0.1MG |
|
J9354 | INJ, ADO-TRASTUZUMAB EMT 1MG | STEP THERAPY |
J9355 | INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR 10 MG | STEP THERAPY |
J9356 | INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK | STEP THERAPY |
J9395 | INJECTION, FULVESTRANT, 25 MG |
|
J9400 | INJ, ZIV-AFLIBERCEPT, 1MG |
|
J9999 | NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS |
|
Q0138 | FERUMOXYTOL, NON-ESRD |
|
Q0515 | INJECTION, SERMORELIN ACETATE, 1 MICROGRAM |
|
Q2026 | RADIESSE INJECTION |
|
Q2027 | SCULPTRA INJECTION |
|
Q2028 | INJ, SCULPTRA, 0.5MG |
|
Q2041 | KTE-C19 TO 200 M A ANTI-CD19 CAR POS T CE P TD | STEP THERAPY |
Q2042 | TISAGENLECLEUCEL TO 600 M CAR-POS VI T CE PER TD | STEP THERAPY |
Q2043 | SIPLEUCEL-T AUTO CD54+ | STEP THERAPY |
Q2050 | DOXORUBICIN INJ 10MG |
|
Q2053 | BREXUCABTAGENE AUTOLCL AU ANTI-CD19 CAR P V T C | STEP THERAPY |
Q2055 | Idecabtagene vicleucel, up to 460 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
|
Q2056 | CILTACABTAGENE AUTOLEUCEL | NEW STEP THERAPY 2023 JANUARY |
Q3027 | INJ BETA INTERFERON IM 1 MCG |
|
Q4074 | ILOPROST NON-COMP UNIT DOSE |
|
Q4081 | INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS) | STEP THERAPY |
Q5101 | INJ FILGRASTIM BIOSIMILAR 1 MCG |
|
Q5103 | INJECTION, INFLECTRA |
|
Q5104 | INJECTION, RENFLEXIS |
|
Q5106 | INJECTION EPOETIN ALFA-EPBX BIOSIMILAR 1000 U |
|
Q5107 | INJECTION BEVACIZUMAB-AWWB BIOSIMILAR 10 MG |
|
Q5108 | INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG | STEP THERAPY |
Q5109 | INJECTION INFLIXIMAB-QBTX BIOSIMILAR 10 MG | STEP THERAPY |
Q5110 | INJ FILGRASTIM-AAFI BIOSIMILR 1 MCG | STEP THERAPY |
Q5111 | INJECTION, PEGFILGRASTIM-CBQV, BIOSIMILAR, (UDENYCA), 0.5 MG | STEP THERAPY |
Q5112 | INJECTION TRASTUZUMAB-DTTB BIOSIMILAR 10 MG | STEP THERAPY |
Q5113 | INJECTION TRASTUZUMAB-PKRB BIOSIMILAR 10 MG | STEP THERAPY |
Q5114 | INJECTION TRASTUZUMAB-DKST BIOSIMILAR 10 MG | STEP THERAPY |
Q5115 | INJECTION RITUXIMAB-ABBS BIOSIMILAR 10 MG | STEP THERAPY |
Q5116 | INJECTION TRASTUZUMAB-QYYP BIOSIMILAR 10 MG |
|
Q5117 | INJECTION TRASTUZUMAB-ANNS BIOSIMILAR 10 MG | STEP THERAPY |
Q5118 | INJECTION, BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG |
|
Q5119 | INJECTION RITUXIMAB-PVVR BIOSIMILAR RUXIENCE 10 MG |
|
Q5120 | INJECTION PEGFILGRASTIM-BMEZ BIOSIMLR ZIEXTENZO 0.5 MG | STEP THERAPY |
Q5121 | INJECTION INFLIXIMAB-AXXQ BIOSIMILAR AVSOLA 10 MG | STEP THERAPY |
Q5122 | INJECTION PEGFILGRASTIM APGF BIOSIMILAR 0.5 MG | STEP THERAPY |
Q5123 | INJECTION RITUXIMAB-ARRX BIOSIMILAR 10 MG | STEP THERAPY |
Q5124 | INJECTION, RANIBIZUMAB-NUNA, BIOSIMILAR, (BYOOVIZ), 0.1 MG | NEW STEP THERAPY 2023 JANUARY |
Q5125 | INJECTION, FILGARASTIM-AYOW, BIOSIMILAR, (RELEUKO), 1 MCG | NEW STEP THERAPY 2023 JANUARY |
Q9991 | BUPRENORPH XR 100 MG OR LESS |
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Q9992 | BUPRENORPHINE XR OVER 100 MG |
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S0013 | ESKETAMINE NASAL SPRAY 1 MG |
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S0145 | INJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER ML |
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