Ascension Personalized Care Specialty Drug List

Product list with current requirements.

Medical benefit specialty medication formulary

HCPCS code Brand Name Generic Name HCPCS Description Requirement Requirement Effective Date Clinical Category
J3262 Actemra Tocilizumab Injection, Tocilizumab, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J0791 Adakveo Crizanlizumab-Tmca Injection, Crizanlizumab-Tmca, 5 mg PA Request 4/1/23 Sickle Cell Disease
J9042 Adcetris Brentuximab Injection, Brentuximab Vedotin, 1 mg PA Request 4/1/23 Oncology
J0172 Aduhelm Aducanumab-Avwa Injection, Aducanumab-avwa, 2 mg PA Request 4/1/23 Antidementia Agent
J9057 Aliqopa Copanlisib Injection, Copanlisib, 1 mg PA Request 4/1/23 Oncology
J2469 Aloxi Palonosetron hcl Injection, palonosetron hcl, 25 mcg No PA/No Precert Required N/A Anti-emetics
J1426 Amondys 45 Casimersen Injection, Casimersen, 10 mg PA Request 1/1/23 Duchenne Muscular Dystrophy (DMD)
J0225 Amvuttra Vutrisiran Injection, Vutrisiran, 1 mg PA Request 8/1/23 RNAi Therapy (hATTR amyloidosis)
J2430 Aredia Pamidronate disodium Injection, pamidronate disodium, per 30 mg No PA/No Precert Required N/A Osteoporosis
J9302 Arzerra Ofatumumab Injection, Ofatumumab, 10 mg PA Request 4/1/23 Oncology
J9035 Avastin Bevacizumab Injection, Bevacizumab, 10 mg PA Request 4/1/23 Oncology
Q5121 Avsola Infliximab-Axxq Injection, Infliximab-Axxq, biosimilar, (Avsola), 10mg PA Request 8/1/23 Auto-Inflammatory Conditions
J0490 Benlysta IV Belimumab Injection, Belimumab, 10 mg PA Request 4/1/23 Systemic Lupus Erythematosus (SLE)
J0179 Beovu Brolucizumab Injection, Brolucizumab-dbll, 1 mg PA Request 4/1/23 Macular Degeneration
J9229 Besponsa Inotuzumab Ozogamicin Injection, Inotuzumab ozogamicin, 0.1 mg PA Request 4/1/23 Oncology
C9142 Bevacizumab (Alymsys) Bevacizumab-maly Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg No PA/No Precert Required N/A Oncology
J9039 Blincyto Blinatumomab Injection, Blinatumomab, 1 microgram PA Request 4/1/23 Oncology
J1740 Boniva Ibandronate sodium Injection, ibandronate sodium, 1 mg No PA/No Precert Required N/A Osteoporosis
J0585 Botox Onabotulinumtoxina Injection, Onabotulinumtoxina, 1 unit PA Request 4/1/23 Neurotoxin
J0567 Brineura Cerliponase Alfa Injection, Cerliponase alfa, 1 mg PA Request 4/1/23 Enzyme Deficiency
Q5124 Byooviz Ranibizumab-Nuna Injection, Ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg PA Request 8/1/23 Macular Degeneration
J0741 Cabenuva Cabotegravir/Rilpivirine Injection, Cabotegravir and Rilpivirine, 2mg/3mg PA Request 4/1/23 HIV/AIDS
J1786 Cerezyme Imiglucerase Injection, Imiglucerase, 10 units PA Request 4/1/23 Enzyme Deficiency
J0717 Cimzia Certolizumab Injection, Certolizumab Pegol, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J2786 Cinqair Reslizumab Injection, Reslizumab, 1 mg PA Request 4/1/23 Asthma
J0584 Crysvita Burosumab Injection, Burosumab-twza 1 mg PA Request 4/1/23 Metabolic Conditions
J9308 Cyramza Ramucirumab Injection, Ramucirumab, 5 mg PA Request 4/1/23 Oncology
J9348 Danyelza Naxitamab-Gqgk Injection, Naxitamab-gqgk, 1 mg PA Request 4/1/23 Oncology
J9145 Darzalex Daratumumab Injection, Daratumumab 10 mg PA Request 4/1/23 Oncology
J9144 Darzalex Faspro Daratumumab / Hyaluronidase-Fihj Injection, Daratumumab, 10 mg and hyaluronidase-fihj PA Request 4/1/23 Oncology
J7318 Durolane Hyaluronan Or Derivative Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg PA Request 4/1/23 Osteoarthritis
J0586 Dysport Abobotulinumtoxina Injection, Abobotulinumtoxina, 5 units PA Request 4/1/23 Neurotoxin
J3060 Elelyso Taliglucerase Alfa Injection, Taliglucerase alfa, 10 units PA Request 4/1/23 Enzyme Deficiency
J9176 Empliciti Elotuzumab Injection, Elotuzumab, 1mg PA Request 4/1/23 Oncology
J1438 Enbrel Etanercept Injection, Etanercept, 25 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J9358 Enhertu Fam-Trastuzumab Deruxtecan-Nxki Injection, Fam-trastu deru-nxki 1mg PA Request 4/1/23 Oncology
J3380 Entyvio Vedolizumab Injection, Vedolizumab, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J0885 Epogen/Procrit Epoetin Alfa Injection, Epoetin Alfa, (for non-ESRD use), 1000 units PA Request 4/1/23 Anemia
Q4081 Epogen/Procrit Epoetin Alfa Injection, Epoetin Alfa, 100 units (for ESRD on dialysis) PA Request 4/1/23 Anemia (Dialysis)
J9055 Erbitux Cetuximab Injection, Cetuximab, 10 Mg PA Request 4/1/23 Oncology
J7323 Euflexxa Hyaluronan or derivative Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose No PA/No Precert Required N/A Osteoarthritis
J3111 Evenity Romosozumab Injection, Romosozumab-aqqg 1 mg PA Request 4/1/23 Osteoporosis
J1428 Exondys 51 Eteplirsen Injection, Eteplirsen, 10 mg PA Request 1/1/23 Duchenne Muscular Dystrophy (DMD)
J0178 Eylea Aflibercept Injection, Aflibercept, 1 mg PA Request 4/1/23 Macular Degeneration
J0517 Fasenra Benralizumab Injection, Benralizumab, 1 mg PA Request 4/1/23 Asthma
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
J9155 Firmagon Degarelix Injection, Degarelix, 1 mg PA Request 4/1/23 Oncology
J9307 Folotyn Pralatrexate Injection, Pralatrexate, 1 mg PA Request 4/1/23 Oncology
Q5108 Fulphila Pegfilgrastim-Jmdb Injection, Pegfilgrastim-jmdb (Fulphila), biosimilar, 0.5 mg PA Request 8/1/23 Neutropenia
J9301 Gazyva Obinutuzumab Injection, Obinutuzumab, 10 mg PA Request 4/1/23 Oncology
J7326 Gel-One Hyaluronan Or Derivative Hyaluronan or derivative, Gel-one, for intra-articular injection, per dose PA Request 4/1/23 Osteoarthritis
J7328 Gelsyn-3 Hyaluronan Or Derivative Hyaluronan or derivative, Gelsyn-3, for intra-articular injection, 0.1 mg PA Request 4/1/23 Osteoarthritis
J7320 Genvisc 850 Hyaluronan Or Derivative Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1 mg PA Request 4/1/23 Osteoarthritis
J9179 Halaven Eribulin Mesylate Injection, Eribulin mesylate, 0.1 mg PA Request 4/1/23 Oncology
J7170 Hemlibra Emicizumab Injection, Emicizumab-kxwh, 0.5 mg PA Request 4/1/23 Hemophilia
J9355 Herceptin Trastuzumab Injection, Trastuzumab, excludes biosimilar, 10 mg PA Request 4/1/23 Oncology
J9356 Herceptin Hylecta Trastuzumab / Hyaluronidase-Oysk Injection, Trastuzumab, 10 mg and hyaluronidase-oysk PA Request 4/1/23 Oncology
Q5113 Herzuma Trastuzumab-pkrb Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg No PA/No Precert Required N/A Oncology
J0135 Humira Adalimumab Injection, Adalimumab, 20 mg PA Request 4/1/23 Auto-Inflammatory Conditions
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
J7322 Hymovis Hyaluronan Or Derivative Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg PA Request 4/1/23 Osteoarthritis
J0638 Ilaris Canakinumab Injection, Canakinumab, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J3245 Ilumya Tildrakizumab Injection, Tildrakizumab, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J7313 Iluvien Fluocinolone Acetonide Injection, Fluocinolone Acetonide intravitreal implant, 0.01 mg PA Request 4/1/23 Ophthalmic Disorders
J9173 Imfinzi Durvalumab Injection, Durvalumab, 10 mg PA Request 4/1/23 Oncology
J9325 Imlygic Talimogene Laherparepvec Injection, Talimogene Laherparepvec, per 1 million plaque forming units PA Request 1/1/23 Auto-Inflammatory Conditions
J1750 Infed Iron Dextran Injection, iron dextran, 50 mg No PA/No Precert Required N/A Anemia
Q5103 Inflectra Infliximab–Dyyb Injection, Infliximab-Dyyb, biosimilar, (Inflectra), 10 mg PA Request 8/1/23 Auto-Inflammatory Conditions
J1439 Injectafer Ferric Carboxymaltose Injection, Ferric Carboxymaltose, 1 mg PA Request 4/1/23 Anemia
Q5109 Ixifi Infliximab-qbtx Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg No PA/No Precert Required N/A Auto-inflammatory Conditions
J9354 Kadcyla Ado-Trastuzumab Emtansine Injection, Ado-trastuzumab emtansine, 1 mg PA Request 4/1/23 Oncology
Q5117 Kanjinti Trastuzumab-anns Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg No PA/No Precert Required N/A Oncology
J2425 Kepivance Palifermin Injection, Palifermin 50 mg PA Request 4/1/23 Oncology
J9271 Keytruda Pembrolizumab Injection, Pembrolizumab, 1 mg PA Request 4/1/23 Oncology
J2507 Krystexxa Pegloticase Injection, Pegloticase, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J9047 Kyprolis Carfilzomib Injection, Carfilzomib, 1 mg PA Request 4/1/23 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
J0202 Lemtrada Alemtuzumab Injection, Alemtuzumab, 1 mg PA Request 4/1/23 Multiple Sclerosis
J1306 Leqvio Inclisiran Injection, Inclisiran, 1 mg PA Request 4/1/23 Hypercholesterolemia
J9119 Libtayo Cemiplimab-Rwlc Injection, Cemiplimab-rwlc, 1 mg PA Request 4/1/23 Oncology
J2778 Lucentis Ranibizumab Injection, Ranibizumab, 0.1 mg PA Request 4/1/23 Macular Degeneration
J0221 Lumizyme Alglucosidase Alfa Injection, Alglucosidase alfa, (lumizyme), 10 mg PA Request 4/1/23 Enzyme Deficiency
J1950 Lupron Depot Leuoprolide Acetate Injection, Leuprolide acetate (for depot suspension), per 3.75 mg PA Request 4/1/23 Oncology
J1954 Lutrate Leuprolide Acetate Injection, Leuprolide Acetate for depot suspension (lutrate), 7.5 mg PA Request 8/1/23 Oncology
J3398 Luxturna Voretigene Neparvovec Injection, Voretigene Neparvovec-rzyl, 1 billion vector genomes PA Request 4/1/23 Leber Congenital Amaurosis
J2503 Macugen Pegaptanib Injection, Pegaptanib sodium, 0.3 mg PA Request 4/1/23 Macular Degeneration
J1726 Makena Hydroxyprogesterone Caproate Injection, Hydroxyprogesterone Caproate, (makena), 10 mg PA Request 4/1/23 Endocrine Disorders
J9349 Monjuvi Tafasitamab-Cxix Injection, Tafasitamab-cxix PA Request 4/1/23 Oncology
J1437 Monoferric Ferric Derisomaltose Injection, Ferric Derisomaltose, 10 mg PA Request 4/1/23 Anemia
J7327 Monovisc Hyaluronan Or Derivative Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose PA Request 4/1/23 Osteoarthritis
Q5107 Mvasi Bevacizumab-Awwb Injection, Bevacizumab-awwb, biosimilar, (mvasi), 10 mg PA Request 8/1/23 Oncology
J0587 Myobloc Rimabotulinumtoxinb Injection, Rimabotulinumtoxinb, 100 units PA Request 4/1/23 Neurotoxin
J0220 N/A Alglucosidase Alfa Injection, Alglucosidase alfa, 10 mg PA Request 4/1/23 Enzyme Deficiency
J9044 N/A Bortezomib Inj, Bortezomib, nos, 0.1 mg PA Request 4/1/23 Oncology
J7330 N/A MACI implant Autologous Cultured Chondrocytes, implant PA Request 1/1/23 Osteoarthritis
Q4082 N/A Misc Drug or Biological, not otherwise classified, Part B Drug Competitive Acquisition Program (CAP) PA Request 1/1/23 Misc
J9314 N/A Pemetrexed (Teva) Injection, Pemetrexed (Teva) not therapeutically equivalent to J9305, 10 mg PA Request 8/1/23 Oncology
J9048 N/A
 Bortezomib (Fresenius Kabi) Injection, Bortezomib (Fresenius Kabi), not therapeutically equivalent to j9041, 0.1 mg PA Request 8/1/23 Oncology
J9049 N/A
 Bortezomib (Hospira) Injection, Bortezomib (Hospira), not therapeutically equivalent to j9041, 0.1 mg PA Request 8/1/23 Oncology
J9046 N/A
 Bortezomib (Dr. Reddy's) Injection, Bortezomib, (Dr. Reddy's), not therapeutically equivalent to j9041, 0.1 mg PA Request 8/1/23 Oncology
J0893 N/A
 Decitabine (Sun) Injection, Decitabine (Sun Pharma) not therapeutically equivalent to j0894, 1 mg PA Request 8/1/23 Oncology
J9394 N/A
 Fulvestrant (Fresnius) Injection, Fulvestrant (Fresenius Kabi) not therapeutically equivalent to j9395, 25 mg PA Request 8/1/23 Oncology
J9393 N/A
 Fulvestrant (Teva) Injection, Fulvestrant (Teva) not therapeutically equivalent to j9395, 25 mg PA Request 8/1/23 Oncology
J1458 Naglazyme Galsulfase Injection, Galsulfase, 1 mg PA Request 4/1/23 Enzyme Deficiency
J2506 Neulasta Pegfilgrastim Injection, Pegfilgrastim, excludes biosimilar, 0.5 mg PA Request 4/1/23 Neutropenia
J1442 Neupogen Filgrastim Injection, Filgrastim (G-CSF), (Neupogen) excludes biosimilars, 1 mcg PA Request 4/1/23 Neutropenia
J0219 Nexviazyme Avalglucosidase Alfa-Ngpt Injection, Avalglucosidase alfa-ngpt, 4 mg PA Request 4/1/23 Enzyme Deficiency
Q5110 Nivestym Filgrastim-Aafi Injection, Filgrastim-aafi, biosimilar, (Nivestym), 1 microgram PA Request 8/1/23 Neutropenia
J3490 Not Otherwise Classified Unclassified drugs Drugs Unclassified injection PA Request 4/1/23 Misc
J3590 Not Otherwise Classified Unclassified biologics Unclassified Biologics PA Request 1/1/23 Misc
J2796 Nplate Romiplostim Injection, Romiplostim, 10 mg PA Request 4/1/23 Thrombocytopenia
J2182 Nucala Mepolizumab Injection, Mepolizumab, 1 mg PA Request 4/1/23 Asthma
J0485 Nulojix Belatacept Injection, Belatacept, 1 mg PA Request 4/1/23 Immunosuppresive Agent
Q5122 Nyvepria Pegfilgrastim-Apgf Injection, Pegfilgrastim-apgf (Nyvepria), biosimilar, 0.5 mg PA Request 8/1/23 Neutropenia
J2350 Ocrevus Ocrelizumab Injection, Ocrelizumab, 1 mg PA Request 4/1/23 Multiple Sclerosis
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
J9299 Opdivo Nivolumab Injection, Nivolumab, 1 mg PA Request 4/1/23 Oncology
J0129 Orencia Abatacept Injection, Abatacept, 10 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J7324 Orthovisc Hyaluronan Or Derivative Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose PA Request 4/1/23 Osteoarthritis
J9306 Perjteta Pertuzumab Injection, Pertuzumab, 1 mg PA Request 4/1/23 Oncology
J9316 Phesgo Pertuzumab / Trastuzumab / Hyaluronidase-Zzxf Injection, Pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg PA Request 4/1/23 Oncology
J9204 Poteligeo Mogamulizumab-Kpkc Injection, Mogamulizumab-kpkc, 1 mg PA Request 4/1/23 Oncology
J0897 Prolia Denosumab Injection, Denosumab, 1 mg PA Request 4/1/23 Osteoporosis
J1301 Radicava Edaravone Injection, Edaravone, 1 mg PA Request 4/1/23 Amyotrophic Lateral Sclerosis (ALS)
J0896 Reblozyl Luspatercept-Aamt Injection, Luspatercept-aamt 0.25mg PA Request 4/1/23 Myelodysplastic Syndrome (MDS)
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
J1745 Remicade Infliximab Injection, Infliximab, excludes biosimilar, 10 mg PA Request 4/1/23 Auto-Inflammatory Conditions
Q5104 Renflexis Infliximab-Abda Injection, Infliximab-Abda, biosimilar, (Renflexis), 10 mg PA Request 8/1/23 Auto-Inflammatory Conditions
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
Q5123 Riabni Rituximab-Arrx Injection, Rituximab-arrx, biosimilar, (riabni), 10 mg PA Request 8/1/23 Oncology
J9312 Rituxan Infliximab Injection, Rituximab, 10 mg PA Request 4/1/23 Oncology
J9311 Rituxan Hycela Rituximab/Hyaluronidase Injection, Rituximab 10 mg and hyaluronidase PA Request 4/1/23 Oncology
Q5119 Ruxience Rituximab-Pvvr Injection, Rituximab-pvvr, biosimilar, (ruxience), 10 mg PA Request 8/1/23 Oncology
Q5119 Ruxience Rituximab-pvvr Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg No PA/No Precert Required N/A Auto-inflammatory Conditions
J2353 Sandostatin LAR Octreotide Injection, Octreotide, Depot Form for Intramuscular Injection, 1 Mg PA Request 4/1/23 Endocrine Disorders
J1602 Simponi Aria Golimumab Injection, Golimumab, 1 mg, for intravenous use PA Request 4/1/23 Auto-Inflammatory Conditions
J2327 Skyrizi Risankizumab Injection, Risankizumab-Rzaa, intravenous, 1 mg PA Request 8/1/23 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
J1300 Soliris Eculizumab Injection, Eculizumab, 10 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J1930 Somatuline Depot Lanreotide Injection, Lanreotide, 1 mg PA Request 4/1/23 Endocrine Disorders
J2326 Spinraza Nusinersen Injection, Nusinersen, 0.1 mg PA Request 4/1/23 Spinal Muscular Atrophy
J3358 Stelara IV Ustekinumab Ustekinumab, for intravenous injection, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J3357 Stelara SC Ustekinumab Ustekinumab, for subcutaneous injection, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
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
J1627 Sustol Granisetron (Extended-Release) Injection, Granisetron, extended-release, 0.1 mg PA Request 4/1/23 Anti-emetic
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
J9022 Tecentriq Atezolizumab Injection, Atezolizumab,10 mg PA Request 4/1/23 Oncology
J3241 Tepezza Teprotumumab-Trbw Injection, Teprotumumab-trbw, 10 mg PA Request 4/1/23 Thyroid Eye Disease (TED)
J2356 Tezspire Tezepelumab-Ekko Injection, Tezepelumab-ekko, 1 mg PA Request 4/1/23 Asthma
Q5116 Trazimera Trastuzumab-qyyp Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg No PA/No Precert Required N/A Oncology
J9033 Treanda Bendamustine Injection, Bendamustine hcl (treanda), 1 mg PA Request 4/1/23 Oncology
J3315 Trelstar Triptorelin Pamoate Injection, Triptorelin Pamoate 3.75 mg (Trelstar) PA Request 4/1/23 Oncology
J1628 Tremfya Guselkumab Injection, Guselkumab, 1 mg PA Request 4/1/23 Auto-Inflammatory Conditions
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
J7332 Triluron Hyaluronan Or Derivative Hyaluronan or derivative, Triluron, for intra-articular injection, 1 mg PA Request 4/1/23 Osteoarthritis
J3316 Triptodur Triptorelin Injection, Triptorelin, extended-release, 3.75 mg PA Request 4/1/23 Oncology
J7329 Trivisc Hyaluronan Or Derivative Hyaluronan or derivative, Trivisc, for intra-articular injection, 1 mg PA Request 4/1/23 Osteoarthritis
J9317 Trodelvy Sacituzumab Govitecan-Hziy Injection, Sacituzumab Govitecan-Hziy, 2.5 Mg PA Request 4/1/23 Oncology
Q5115 Truxima Rituximab-Abbs Injection, Rituximab-abbs, biosimilar, (Truxima), 10 mg PA Request 8/1/23 Oncology
J2323 Tysabri Natalizumab Injection, Natalizumab, 1 mg PA Request 4/1/23 Multiple Sclerosis
Q5111 Udenyca Pegfilgrastim-Cbqv Injection, Pegfilgrastim-cbqv (Udenyca), biosimilar, 0.5 mg PA Request 8/1/23 Neutropenia
J1303 Ultomiris Ravulizumab Injection, Ravulizumab-cwvz, 10 mg PA Request 4/1/23 Auto-Inflammatory Conditions
J9399 Unclassified Drugs or Biologicals Chemotherapy Drugs Chemotherapy Drugs PA Request 1/1/23 Oncology
J1823 Uplizna Inebilizumab-Cdon Injection, Inebilizumab-cdon, 1 Mg PA Request 4/1/23 Auto-Inflammatory Conditions
J9303 Vectibix Panitumumab Injection, Panitumumab, 10 mg PA Request 4/1/23 Oncology
Q5129 Vegzelma Bevacizumab-Adcd Injection, Bevacizumab-adcd (vegzelma), biosimilar, 10 mg PA Request 8/1/23 Oncology
J9041 Velcade Bortezomib Injection, Bortezomib (velcade), 0.1 mg PA Request 4/1/23 Oncology
J1756 Venofer Iron Sucrose Injection, iron sucrose, 1 mg No PA/No Precert Required N/A Anemia
J1427 Viltepso Viltolarsen Injection, Viltolarsen, 10 mg PA Request 1/1/23 Duchenne Muscular Dystrophy (DMD)
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
J3396 Visudyne Verteporfin Injection, Verteporfin, 0.1 Mg PA Request 4/1/23 Ophthalmic Disorders
J3385 Vpriv Velaglucerase Alfa Injection, Velaglucerase alfa, 100 units PA Request 4/1/23 Enzyme Deficiency
J3032 Vyepti Eptinezumab Injection, Eptinezumab-jjmr, 1 mg PA Request 4/1/23 Neurotoxin
J1429 Vyondys 53 Golodirsen Injection, Golodirsen, 10 mg PA Request 1/1/23 Duchenne Muscular Dystrophy (DMD)
J0588 Xeomin Incobotulinumtoxin A Injection, Incobotulinumtoxin a, 1 unit PA Request 4/1/23 Neurotoxin
J0775 Xiaflex Collagenase, Clostridium Histolyticum Injection, Collagenase, clostridium histolyticum, 0.01 mg PA Request 4/1/23 Enzyme
J2357 Xolair Omalizumab Injection, Omalizumab, 5 mg PA Request 4/1/23 Asthma
J9228 Yervoy Ipilimumab Injection, Ipilimumab, 1 mg PA Request 4/1/23 Oncology
Q5101 Zarxio Filgrastim-Sndz Injection, filgrastim-sndz, biosimilar, (Zarxio) 1 microgram PA Request 8/1/23 Neutropenia
J9223 Zepzelca Lurbinectedin Injection, Lurbinectedin, 0.1 Mg PA Request 4/1/23 Oncology
Q5120 Ziextenzo Pegfilgrastim-Bmez Injection, Pegfilgrastim-bmez, (Ziextenzo), biosimilar, 0.5 mg PA Request 8/1/23 Neutropenia
J0565 Zinplava Bezlotoxumab Injection, Bezlotoxumab, 10 mg PA Request 4/1/23 Passive Immunizing and Treatment Agent
Q5118 Zirabev Bevacizumab-Bvzr Injection, Bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg PA Request 8/1/23 Oncology
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
J3399 Zolgensma Onasemnogene abeparvovec Injection, Onasemnogene Abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes PA Request 4/1/23 Spinal Muscular Atrophy
Specialty drug list
APC Medical Specialty Drug List PA Required
Specialty drug list
APC Medical Specialty Drug List No PA Required