Specialty Medications Covered Under Medical Benefits

Medical Injection-Brand Name HPCS Code Effective Date
Botox J0585 10/12/1998
Dysport J0586 10/12/1998
Xeomin J0588 10/12/1998
Myobloc J0587 10/12/1998
Sprinraza J2326 01/01/2018
Ajovy J3031* 3/1/2020
Benlysta IV J0490 3/1/2020
Bivigam J1556 3/1/2020
Carimune, Gammagard S/D, Panglobulin NF J1566 3/1/2020
Cimzia lyophilized powder J0717 3/1/2020
Cuvitru J1555 3/1/2020
Durolane J7318 3/1/2020
Entyvio J3380 3/1/2020
Euflexxa J7323 3/1/2020
Evenity J3111 3/1/2020
Eylea J0178* 3/1/2020
Fasenra J0517* 3/1/2020
Flebogamma J1572 3/1/2020
Fulphila Q5108* 3/1/2020
Gammagard liquid J1569 3/1/2020
Gammaplex J1557 3/1/2020
Gammunex-c, Gammaked J1561 3/1/2020
Gel-one J7326 3/1/2020
Gelsyn 3 J7328 3/1/2020
Genvisc 850 J7320 3/1/2020
H.P. Acthar Gel J0800* 3/1/2020
Hizentra J1559 3/1/2020
Hyalgan, Supartz J7321 3/1/2020
Hymovis J7322 3/1/2020
Hyqvia J1575 3/1/2020
Ilumya J3245 3/1/2020
Inflectra Q5103 3/1/2020
Ixifi Q5109 3/1/2020
Lemtrada J0202 3/1/2020
Lucentis J2778* 3/1/2020
Luxturna J3398* 3/1/2020
Monovisc J7327 3/1/2020
Neulasta J2505* 3/1/2020
Nplate J2796* 3/1/2020
Nucala J2182* 3/1/2020
Ocrevus J2350 3/1/2020
Octagam J1568 3/1/2020
Orencia IV J0129 3/1/2020
Orthovisc J7324 3/1/2020
Panzyga J1599 3/1/2020
Privigen J1459 3/1/2020
Remicade J1745 3/1/2020
Renflexis Q5104 3/1/2020
Simponi Aria J1602 3/1/2020
Stelara IV J3358 3/1/2020
Supprelin LA J9226* 3/1/2020
SynoJoynt J7331 3/1/2020
Synvisc J7325 3/1/2020
Tremfya J1628 3/1/2020
Triluron J7332 3/1/2020
Triptodur J3316* 3/1/2020
Trivisc J7329 3/1/2020
Tysabri J2323 3/1/2020
Udenyca Q5111* 3/1/2020
Xolair J2357* 3/1/2020
Beovu J0179* 8/1/2020
Adakveo J0791* 8/1/2020
Vyondys 53 J1429* 8/1/2020
Zolgensma J3399* 8/1/2020
Visco-3 J7333 8/1/2020

* Not subject to Site of Care Requirement

Biosimilar Drugs

The following is a list of preferred biosimilar drugs. Use of preferred biosimilar product prior to the use of non-preferred product is required. Please note the preferred biosimilar are subject to prior authorization.

Non-Preferred Medical Injection Drug Preferred Biosimilar Effective Date
Remicade (J1745) Renflexis (Q5104) 3/1/2020
Neulasta (J2505) Fulphila (Q5108) & Udenyca (Q5111) 3/1/2020

 

To request prior authorization, submit the Medical Injectable Prior Authorization form along with clinical supporting documentation via fax to 410-424-2801.