Ascension Personalized Care Specialty Drug List
Product list with current requirements.
No prior authorization or precertification required
| HCPCS code | Brand Name | Generic Name | HCPCS Description | Requirement | Requirement Effective Date | Clinical Category |
| J2469 | Aloxi | Palonosetron hcl | Injection, palonosetron hcl, 25 mcg | No PA/No Precert Required | N/A | Anti-emetics |
| J2430 | Aredia | Pamidronate disodium | Injection, pamidronate disodium, per 30 mg | No PA/No Precert Required | N/A | Osteoporosis |
| C9142 | Bevacizumab (Alymsys) | Bevacizumab-maly | Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg | No PA/No Precert Required | N/A | Oncology |
| J1740 | Boniva | Ibandronate sodium | Injection, ibandronate sodium, 1 mg | No PA/No Precert Required | N/A | Osteoporosis |
| J7323 | Euflexxa | Hyaluronan or derivative | Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose | No PA/No Precert Required | N/A | Osteoarthritis |
| 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 |
| Q5113 | Herzuma | Trastuzumab-pkrb | Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg | No PA/No Precert Required | N/A | Oncology |
| 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 |
| J1750 | Infed | Iron Dextran | Injection, iron dextran, 50 mg | No PA/No Precert Required | N/A | Anemia |
| Q5109 | Ixifi | Infliximab-qbtx | Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg | No PA/No Precert Required | N/A | Auto-inflammatory Conditions |
| Q5117 | Kanjinti | Trastuzumab-anns | Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg | No PA/No Precert Required | N/A | Oncology |
| 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 |
| Q5114 | Ogivri | Trastuzumab-dkst | Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg | No PA/No Precert Required | N/A | Oncology |
| Q5112 | Ontruzant | Trastuzumab-dttb | Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg | No PA/No Precert Required | N/A | Oncology |
| J3489 | Reclast | Zoledronic acid | Injection, zoledronic acid, 1 mg | No PA/No Precert Required | N/A | Endocrine Disorders |
| Q5125 | Releuko | Filgrastim-ayow, | Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram | No PA/No Precert Required | N/A | Neutropenia |
| Q5105, Q5106 | Retacrit | Epoetin alfa-epbx | Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units | No PA/No Precert Required | N/A | Anemia |
| Q5119 | Ruxience | Rituximab-pvvr | Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg | No PA/No Precert Required | N/A | 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 |
| 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 |
| J7331 | Synojoynt | Hyaluronan or derivative | Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg | No PA/No Precert Required | N/A | Osteoarthritis |
| 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 |
| Q5116 | Trazimera | Trastuzumab-qyyp | Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg | No PA/No Precert Required | N/A | Oncology |
| 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 |
| J1756 | Venofer | Iron Sucrose | Injection, iron sucrose, 1 mg | No PA/No Precert Required | N/A | Anemia |
| J7321 | Visco-3 | 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 |
| J2405 | Zofran | Ondansetron | Injection, ondansetron hydrochloride | No PA/No Precert Required | N/A | Anti-emetics |
| J3489 | Zoledronic Acid | Zoledronic acid | Injection, zoledronic acid, 1 mg | No PA/No Precert Required | N/A | Endocrine Disorders |