INJECTABLES/MEDICATIONS ADMINISTERED UNDER THE MEDICAL BENEFIT Authorization Required List Not Related to Bleeding and Clotting Disorders

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1 INJECTABLES/MEDICATIONS ADMINISTERED UNDER THE MEDICAL BENEFIT Authorization Required List Not Related to Bleeding and Clotting Disorders CareOregon and Revised 6/01/2016 INSTRUCTIONS FOR USE: 1. This list contains Injectable Medications covered under the Medical Benefit that REQUIRE AUTHORIZATION. Always search by J-Code AND by Drug Name because J-Codes change. Note: See and OHP columns for pertinent information. Prior Authorization Request forms can be found at 2. This document should NOT be used for: hemophilia/factor/bleeding products OR drugs furnished by a pharmacy (For Medicaid, CareOregon requires buy and bill for drugs administered in office in accordance with OAR: (3)). 3. VACCINES: Only certain vaccines with unique benefits are listed below. Vaccines not listed are still subject to appropriate use/billing practices including Medicare billing requirements (see following). For COA members: Most preventative vaccines are covered by Part D (pharmacy benefit) and not by Part B (office buy and bill). Typically, Part B only covers pneumococcal, influenza, hepatitis B for individuals at high or intermediate risk, and tetanus toxoid or rabies directly related to the treatment of an injury or direct exposure. All other vaccines should be dispensed at a pharmacy for Medicare members. 4. If the drug is NOT found on this list AND will be Buy and Bill (Supplied and billed under the Medical Benefit by the Provider) then it does NOT require authorization. EXCEPTION: New drugs to the market not found on this list. Dump Codes C9399, J3590 and J9999 require Prior Authorization for ANY medication being billed under them whether listed below or not. 5. J3490 (unclassified drugs)- Should only be used for drugs without a more specific code. Auth only required IF drug name is on the list below. **Always use the most active code based on date of service and CMS HCPCS codes** J0129 Abatacept Orencia SQ- Med D only IV-PA Required J0586 Abobotulinumtoxin A Dysport J0135 Adalimumab Humira - Part D only

2 J9354 Ado-trastuzumab Kadcyla J0178 Aflibercept Eylea J0180 Agalsidase beta Fabrazyme J3490 Albiglutide Tanzeum - Part D only - Pharmacy Benefit J0215 Alefacept Amevive J0202 Q9979* Alemtuzumab Lemtrada J0202 Alemtuzumab Campath J9010* J0205 Alglucerase Ceredase J0221 Alglucosidase alfa Lumizyme J0220 Alglucosidase alfa Myozyme J3490 Alirocumab Praluent - Part D only - Pharmacy Benefit J0256 Alpha-1 Proteinase Inhibitor Prolastin J0257 Alpha-1 Proteinase Inhibitor (human) Glassia J0270 Alprostadil, injection Caverject, Edex Not covered Not covered J0275 Alprostadil, urethral suppository Muse Not covered Not covered J3450 Anakinra Kineret - Part D only J0365 Aprotinin Trasylol J9019 Asparaginase Erwinia Erwinaze J0401 Aripiprazole, injection extended release Abilify Maintena - Excluded Bill to C9470 J3490 Aripiprazole, injection extended release Aristada - Excluded Bill to J3490, J3590 Asfotase alfa Strensiq - Part D only - Pharmacy Benefit J7330 Autologous Cultured Chondrocytes Carticel Not covered Not covered J0485 Belatacept Nulojix J0490 Belimumab Benlysta

3 J9032 C9442*, J9999* Belinostat Beleodaq J9033 Bendamustine Treanda J9999 or J9033 Bendamustine Bendeka J9035 Bevacizumab for CHEMOTHERAPY * bevacizumab for eye use should use J7999 and no authorization is required Avastin for CHEMOTHERAPY J9039 Blinatumomab Blincyto C9449* J9041 Bortezomib Velcade J9042 Brentuximab vedotin Adcetris J0571 Buprenorphine Subutex Part D only Pharmacy J0572 Buprenorphine/Naloxone Suboxone Dispenses= J0573 Buprenorphine/Naloxone Suboxone Pharmacy Pharmacy Benefit J0574 Buprenorphine/Naloxone Suboxone Dispenses: Phamacy with PA J0575 Buprenorphine/Naloxone Suboxone Benefit with PA. Clinic Dispenses: Excluded Clinic Dispenses= Behavioral Health Benefit with PA J0598 C1 esterase inhibitor Cinryze J9043 Cabazitaxel Jevtana J0630 Calcitonin salmon Miacalcin, Calcimar - Part D only No PA Reqd J0638 Canakinumab Ilaris J7340 Carbidopa/Levodopa Duopa J9047 Carfilzomib Kyprolis J7335 Capsaicin patch Qutenza J0712 Ceftaroline fosamil Teflaro J0714 J3490* Ceftazidime/Avivactam Avycaz

4 J0717 Certolizumab Cimzia - Part D only J9055 Cetuximab Erbitux J0775 Collagenase clostridium histolyticum Xiaflex J0800 Corticotropin Acthar gel - Part D only J9999 Daratumumab Darzalex J0881 Darbepoetin Aranesp J0894 Decitabine Dacogen J0897 Denosumab Prolia, Xgeva J2597 Desmopressin acetate DDAVP J9999 Dinutuximab Unituxin J9171 Docetaxel Taxotere Q2049 Doxorubicin, liposomal. Imported Lipodox Q2050 Doxorubicin, liposomal Doxil J1300 Eculizumab Soliris J1322 Elosulfase alfa Vimizim J9999 Elotuzumab Empliciti J1324 Enfuvirtide Fuzeon Part D only, No auth required. J0885 Epoetin alfa (non-esrd) Procrit J0888 Epoetin beta (non-esrd) NeoRecormon J1325 Epoprostenol Flolan S0155 Epoprostenol Diluent Flolan Diluent J9179 Eribulin Halaven J1438 Etanercept Enbrel - Part D only J7527 Everolimus (oral) Afinitor, Zortress J3490 Exenatide Byetta, Bydureon - Part D only - Pharmacy Benefit J1439 Ferric carboxymaltose Injectafer J7311 Fluocinolone implant Retisert J7313 C9450* Fluocinolone implant Iluvien

5 J2680 Fluphenazine No PA Reqd - Excluded Bill to J9395 Fulvestrant Faslodex J1458 Galsulfase Naglazyme J1595 Glatiramer Acetate Copaxone - Part D only Pharmacy Benefit C9293 Glucarpidase Voraxaze J3590 Golimumab Simponi - SQ- Med D only J1602 Golimumab, IV Simponi Aria J9202 Goserelin Zoladex J2940 Growth Hormone (somatrem) Various - Part D only J2941 Growth Hormone (somatropin) Various - Part D only J1630 Haloperidol Haldol No PA Reqd - Excluded Bill to J1631 Haloperidol Haldol No PA Reqd - Excluded Bill to J1675 Histrelin Supprelin - Part D only J9226 Histrelin implant Supprelin LA J9225 Histrelin implant Vantas or Human Papilloma Virus (HPV) vaccine Gardasil, Cervarix - Part D only No auth req. for ages <19 VFC J7323 Hyaluronan or Derivative Euflexxa Not covered J7326 Hyaluronan or Derivative Gel-One Not covered J7321 Hyaluronan or Derivative Hyalgan or Supartz Not covered J7324 Hyaluronan or Derivative Orthovisc Not covered J7325 Hyaluronan or Derivative Synvisc, Synvisc-One Not covered J7327 Hyaluronan or Derivative Monovisc Not covered J7328 Hyaluronan or Derivative Gel-Syn Not covered Q9980 Hyaluronan or Derivative GenVisc Not covered C9471 Hyaluronan or Derivative Hymovis Not covered J1725 Hydroxyprogesterone caproate Makena J1741 Ibuprofen (IV) Caldolor, NeoProfen

6 J1744 Icatibant Firazyr - Part D only No PA Reqd Q4074 Iloprost, Inhaled Ventavis J1786 Imiglucerase Cerezyme J1566 Immune Globulin lyophilized, IV Carimune J1460 Immune Globulin, IM GamaStan SD J1560 J1572 Immune Globulin, IV Flebogamma J1569 Immune Globulin, IV Gammagard J1557 Immune Globulin, IV Gammaplex J1561 Immune Globulin, IV Gamunex J1559 Immune Globulin, SQ Hizentra - Part D only J1599 Immune Globulin, IV Nonlyophilized (NOS) J1568 Immune Globulin, IV Octagam J1459 Immune Globulin, IV, Privigen J1556 Immune Globulin, IV Bivigam J1575 Immune Globulin/hyaluronidase Hyqvia J0588 Incobotulinumtoxin A Xeomin J1745 Infliximab Remicade Influenza Virus Vaccine, High Dose Fluzone High Dose - Part D only No auth req. for age 65 and older J1815 Insulin Humalog, Lantus, etc - Part D only No PA Reqd J1817 Insulin for administration through pump Humalog, Novolog, etc - Part D only No PA Reqd J9215 Interferon Alfa N-3 Alferon-N J9213 Interferon Alfa-2a Roferon A - Part D only J9214 Interferon Alfa-2b Intron A, Rebetron Kit J9212 Interferon Alfacon-1 Infergen - Part D only Q3028 Inferferon Beta-1a, SQ use Rebif, Rebidose - Part D only Pharmacy Benefit Q3027 Inferferon Beta-1a, IM use Avonex - Part D only Pharmacy Benefit J1830 Interferon Beta-1b Betaseron - Part D only Pharmacy Benefit J9216 Interferon Gamma-1B Actimmune - Part D only J7300 Intrauterine Copper Contraceptive Not Covered± No PA Reqd J9228 Ipilimumab Yervoy

7 C9474 J9999 J1833 C9456*, J3490* Irinotecan liposome Onivyde Isavuconazonium Cresemba (IV) J9207 Ixabepilone Ixempra J1931 Laronidase Aldurazyme J9218 Leuprolide Lupron - Part D only J9217 Leuprolide depot Lupron Depot, Eligard J1950 Leuprolide depot suspension Lupron Depot, J9219 Leuprolide implant Lupron Implant J0641 Levoleucovorin Fusilev J7301 Levonorgestrel IUD Skyla Not Covered± No PA Reqd J7297 Levonorgestrel IUD 52 mg, 3 year Liletta Not Covered± No PA Reqd J7302* J7298 Levonorgestrel IUD 52 mg, 5 year Mirena Not Covered± No PA Reqd J7302* J3490 Liraglutide Victoza - Part D only J2010 Lincomycin Lincocin Not Covered J2020 Linezolid Zyvox C9497 Loxapine, inhaled powder Adasuve No PA Reqd - Excluded Bill to J3490 Metreleptin Myalept J2170 Mecasermin Increlex, Iplex - Part D only J9245 Melphalan Alkeran J3590 Melphalan Evomela C9473 Mepolizumab Nucala J3590 J7309 Methyl Aminolevulinate Levulan, Kerastick, Metvixia J2212 Methylnaltrexone Relistor - Part D only J3490 Mipomersen Kynamro - Part D only S1090 Mometasone Furoate Sinus Implant Propel J2315 Naltrexone Extended-release injection Vivitrol

8 J2323 Natalizumab Tysabri C9475 Necitumumab Portrazza J9999 J9261 Nelarabine Arranon J8655 Q9978* Netupitant-palonesetron oral Akynzeo J9299 Nivolumab Opdivo C9453*, J9999* J9301 Obinutuzumab Gazyva J7316 Ocriplasmin Jetrea J2354 Octreotide Sandostatin - Part D only No PA Reqd J9302 Ofatumumab Arzerra J2358 Olanzapine Zyprexa Relprevv No PA Reqd - Excluded Bill to J9262 Omacetaxine mepesuccinate Synribo J2357 Omalizumab Xolair J0585 Onabutolinumtoxin-A Botox J9263 Oxaliplatin Eloxatin J9264 Paclitaxel protein-bound Abraxane J2426 Paliperidone Invega Sustenna - Excluded Bill to Palivizumab Synagis 1. For OHSU providers only, submit request to CareOregon and use own supply. 2. For all other providers, submit request to CareOregon and obtain Synagis from our preferred provider. See the request form for details on the preferred provider. J9303 Panitumumab Vectibix J2440 Papaverine N/A - Part D only No PA Reqd J3490 Parathyroid hormone Natpara - Part D only

9 J2502 Pasireotide Signifor LAR C9454*, J3490* J2504 Pegademase bovine Adagen J2503 Pegaptanib Macugen J9266 Pegaspargase Oncaspar J0890 Peginesatide Omontys J2507 Pegloticase Krystexxa J3590 Pegvisomant Somavert - Part D only J3590, S0145 Pegylated Interferon alfa-2a Pegasys - Part D only J3590, S0148 Pegylated Interferon alfa-2b Peg-Intron - Part D only J3490 Pegylated Interferon alfa-2b Sylatron - Part D only J9271 C9027*, J3590*, Pembrolizumab Keytruda J9999* J9305 Pemetrexed Alimta J9306 Pertuzumab Perjeta J2760 Phentolamine Regitine - Part D only No PA Reqd J2562 Plerixafor Mozobil J9307 Pralatrexate Folotyn J3490 Pramlintide Symlin - Part D only J3490 Polidocanol Varithena J9308 Ramucirumab Cyramza C9025*, J3590*, J9999* J2778 Ranibizumab Lucentis J2793 Rilonacept Arcalyst J0587 RimabotulinumtoxinB Myobloc J2794 Risperidone Risperdal Consta No PA Reqd - Excluded Bill to J9310 Rituximab Rituxan Q0181 Rolapitant Varubi J9315 Romidepsin Istodax J2796 Romiplostim Nplate

10 J3490, J3590 Sebelipase alfa Kanuma J3590 Secukinumab Cosentyx - Part D only J2860 C9455*, J9999*, Siltuximab Sylvant J3590* Q2043 Sipuleucel-T Provenge J3030 Sumatriptan succinate Imitrex Injection - Part D only No PA Reqd J3060 Taliglucerase alfa Elelyso J9999 Talimogene laherparepvec Imlygic C9472 J9328 Temozolomide Temodar J9330 Temsirolimus Torisel J3110 Teriparatide Forteo - Part D only J1071 Testosterone cypionate Various No PA Reqd J3121 Testosterone enanthate Various No PA Reqd J3145 Testosterone undecanoate Aveed J3243 Tigecyclcine Tygacil J3262 Tocilzumab Actemra J9999 Trabectedin Yondelis J9355 Trastuzumab Herceptin J3285 Treprostinil Remodulin J7686 Treprostinil Tyvaso J3315 Triptorelin Trelstar J3355 Urofollitropin Metrodin, Bravelle, Fertinex - Part D only Not covered J3357 Ustekinumab Stelara Varicella zoster immune globulin Varizig J3380 Vedolizumab Entyvio C9026* J3385 Velaglucernase alfa Vpriv J9371 Vincristine sulfate liposome Marqibo J3486 Ziprasidone Geodon No PA Reqd - Excluded Bill to J9400 Ziv-aflibercept Zaltrap

11 90736 Zoster Vaccine live Zostavax - Part D only Age<60 req PA C9399 Unclassified Drug or biologic J3590 Unclassified Biologics J9999 Not otherwise classified, Anti-neoplastic Drugs * Note that ALL codes are subject to change according to CMS HCPCS Codes quarterly updates. CareOregon requires the active code from the date of service to be provided. When in doubt, please always refer to the generic name listing when checking if PA is required. ± Coverage excluded by Medicare. For member's with dual eligibilty, coverage may be offered under their secondary Medicaid (OHP). Drug's with REMOVED PA requirements as of 4/1/16 J9045 Carboplatin Paraplatin No No J9201 Gemcitabine Gemzar No No J9206 Irinotecan Camptosar No No J9267 Paclitaxel Taxol No No J9265* J9185 Fludarabine Fludara No No