Ascension Personalized Care Specialty Drug List

Product list with current requirements.

Prior authorization required

Includes a link using Brand Name to prior authorization clinical criteria for use documents. For those without clinical criteria listed, InterQual will be used.

HCPCS codes Brand Name Generic Name HCPCS Description Requirement Requirement Effective Date Clinical Category
J3262 ACTEMRA Tocilizumab Injection, Tocilizumab, 1 mg PA Request 4/1/2023 Auto-inflammatory Conditions CF
J0791 ADAKVEO Crizanlizumab-Tmca Injection,  Crizanlizumab-tmca 5 mg PA Request 4/1/2023 Sickle Cell Disease
J9042 ADCETRIS Brentuximab Brentuximab Vedotin, 1mg PA Request 4/1/2023 Oncology
J0172 ADUHELM Aducanumab-Avwa Injection, Aducanumab-avwa, 2 mg Exclusion: Medical Necessity Review Required 4/1/2023 Antidementia Agent
J9057 ALIQOPA Copanlisib Injection, Copanlisib, 1 mg PA Request 4/1/2023 Oncology
 J1426 Amondys 45
 Casimersen Injection, Casimersen, 10 mg PA Request 1/1/2023 Duchenne Muscular Dystrophy (DMD)
J0225  Amvuttra
 Vutrisiran Injection, Vutrisiran, 1 mg PA Request 8/1/2023  RNAi Therapy (hATTR amyloidosis)
J9302 ARZERRA Ofatumumab Injection, Ofatumumab, 10 mg  PA Request 4/1/2023 Oncology
J9035 AVASTIN Bevacizumab Injection, Bevacizumab, 10 mg PA Request 4/1/2023 Oncology
 Q5121 Avsola
 Infliximab-Axxq Injecction, Infliximab-Axxq, biosimilar, (Avsola), 10 mg PA Request 8/1/2023 Auto-Inflammatory Conditions
J0490 BENLYSTA IV Belimumab Injection, Belimumab, 10 mg PA Request 4/1/2023 Systemic Lupus Erythematosus (SLE)
J0179 BEOVU Brolucizumab Injection, Brolucizumab-dbll, 1 mg PA Request 4/1/2023 Macular Degeneration
J9229 BESPONSA Inotuzumab Ozogamicin Injection, Inotuzumab ozogamicin, 0.1 mg PA Request 4/1/2023 Oncology
J9039 BLINCYTO Blinatumomab Injection, Blinatumomab, 1 microgram PA Request 4/1/2023 Oncology
J0585 BOTOX Onabotulinumtoxina Injection, Onabotulinumtoxina, 1 unit PA Request 4/1/2023 Neurotoxin
J0567 BRINEURA Cerliponase Alfa Injection, Cerliponase alfa, 1 mg PA Request 4/1/2023 Enzyme Deficiency
Q5124  Byooviz
 Ranibizumab-Nuna Injection, Ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg PA Request 8/1/2023 Macular Degeneration
 J0741 Cabenuva
 Cabotegravir/Rilpivirine Injection, Cabotegravir and Rilpivirine, 2mg/3mg PA Request 4/1/2023 HIV/AIDS
J1786 CEREZYME Imiglucerase Injection, Imiglucerase, 10 units PA Request 4/1/2023 Enzyme Deficiency
J0717 CIMZIA Certolizumab Injection, Certolizumab pegol, 1mg PA Request 4/1/2023 Auto-inflammatory Conditions
J2786 CINQAIR Reslizumab Injection, Reslizumab, 1 mg PA Request 4/1/2023 Asthma
J0584 CRYSVITA Burosumab Injection, Burosumab-twza 1 mg PA Request 4/1/2023 Metabolic Conditions
J9308 CYRAMZA Ramucirumab Injection, Ramucirumab, 5 mg PA Request 4/1/2023 Oncology
J9348 DANYELZA Naxitamab-Gqgk Injection, Naxitamab-gqgk, 1 mg PA Request 4/1/2023 Oncology
J9145 DARZALEX Daratumumab Injection, Daratumumab 10 mg PA Request 4/1/2023 Oncology
J9144 DARZALEX FASPRO Daratumumab / Hyaluronidase-Fihj Injection, Daratumumab, 10 mg and hyaluronidase-fihj PA Request 4/1/2023 Oncology
J7318 DUROLANE Hyaluronan Or Derivative Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg PA Request 4/1/2023 Osteoarthritis
J0586 DYSPORT Abobotulinumtoxina Injection, Abobotulinumtoxina, 5 units PA Request 4/1/2023 Neurotoxins
J3060 ELELYSO Taliglucerase Alfa Injection, Taliglucerase alfa, 10 units PA Request 4/1/2023 Enzyme Deficiency
J9176 EMPLICITI Elotuzumab Injection, Elotuzumab, 1mg PA Request 4/1/2023 Oncology
J1438 ENBREL Etanercept Injection, Etanercept, 25 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J9358 ENHERTU Fam-Trastuzumab Deruxtecan-Nxki Injection, Fam-trastu deru-nxki 1mg PA Request 4/1/2023 Oncology
J3380 ENTYVIO Vedolizumab Injection, Vedolizumab, 1 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J0885 EPOGEN/PROCRIT Epoetin Alfa Injection, Epoetin alfa, (for non-ESRD use), 1000 units PA Request 4/1/2023 Anemia
Q4081 EPOGEN/PROCRIT Epoetin Alfa Injection, Epoetin alfa, 100 units (for ESRD on dialysis) PA Request 4/1/2023 Anemia (Dialysis)
J9055 ERBITUX Cetuximab Injection, Cetuximab, 10 Mg PA Request 4/1/2023 Oncology
J3111 EVENITY Romosozumab Injection, Romosozumab-aqqg 1 mg PA Request 4/1/2023 Osteoporosis
 J1428 Exondys 51
 Eteplirsen Injection, Eteplirsen, 10 mg PA Request 1/1/2023 Duchenne Muscular Dystrophy (DMD)
J0178 EYLEA Aflibercept Injection, Aflibercept, 1 mg PA Request 4/1/2023 Macular Degeneration
J0517 FASENRA Benralizumab Injection, Benralizumab, 1 mg PA Request 4/1/2023 Asthma
J9155 FIRMAGON Degarelix Injection, Degarelix, 1 mg PA Request 4/1/2023 Oncology
J9307 FOLOTYN Pralatrexate Injection, Pralatrexate, 1 mg PA Request 4/1/2023 Oncology
Q5108  Fulphila
 Pegfilgrastim_jmdb Injection, Pegfilgrastim-jmdb (Fulphila), biosimilar, 0.5 mg PA Request 8/1/2023 Neutropenia
J9301 GAZYVA Obinutuzumab Injection, Obinutuzumab, 10 mg PA Request 4/1/2023 Oncology
J7326 GEL-ONE Hyaluronan Or Derivative Hyaluronan or derivative, Gel-one, for intra-articular injection, per dose PA Request 4/1/2023 Osteoarthritis
J7328 GELSYN-3 Hyaluronan Or Derivative Hyaluronan or derivative, Gelsyn-3, for intra-articular injection, 0.1 mg PA Request 4/1/2023 Osteoarthritis
J7320 GENVISC 850 Hyaluronan Or Derivative Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1 mg PA Request 4/1/2023 Osteoarthritis
J9179 HALAVEN Eribulin Mesylate Injection, Eribulin mesylate, 0.1 mg PA Request 4/1/2023 Oncology
J7170 HEMLIBRA Emicizumab Injection, Emicizumab-kxwh, 0.5 mg PA Request 4/1/2023 Hemophilia
J9355 HERCEPTIN Trastuzumab Injection, Trastuzumab, excludes biosimilar, 10 mg PA Request 4/1/2023 Oncology
J9356 HERCEPTIN HYLECTA Trastuzumab / Hyaluronidase-Oysk Injection, Trastuzumab, 10 mg and hyaluronidase-oysk PA Request 4/1/2023 Oncology
J0135 HUMIRA Adalimumab Injection, Adalimumab, 20 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J7322 HYMOVIS Hyaluronan Or Derivative Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg PA Request 4/1/2023 Osteoarthritis
J0638 ILARIS Canakinumab Injection, Canakinumab, 1 mg  PA Request 4/1/2023 Auto-inflammatory Conditions
J3245 ILUMYA Tildrakizumab Injection, Tildrakizumab, 1 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J7313 ILUVIEN Fluocinolone Acetonide Injection, Fluocinolone Acetonide intravitreal implant, 0.01 mg PA Request 4/1/2023 Ophthalmic Disorders
J9173 IMFINZI Durvalumab Injection, Durvalumab, 10 mg PA Request 4/1/2023 Oncology
J9325 Imlygic
 Talimogene Laherparepvec Injection, Talimogene Laherparepvec, per 1 million plaque forming units PA Request 1/1/2023 Auto-inflammatory Conditions
 Q5103 Inflectra
 Infliximab-Dyyb Injection, Infliximab-Dyyb, biosimilar, (Inflectra), 10 mg PA Request 8/1/2023 Auto-Inflammatory Conditions
J1439 INJECTAFER Ferric Carboxymaltose Injection, Ferric carboxymaltose, 1 mg PA Request 4/1/2023 Anemia
J9354 KADCYLA Ado-Trastuzumab Emtansine Injection, Ado-trastuzumab emtansine, 1 mg PA Request 4/1/2023 Oncology
J2425 KEPIVANCE Palifermin Injection, Palifermin 50 mg PA Request 4/1/2023 Oncology
J9271 KEYTRUDA Pembrolizumab Injection, Pembrolizumab, 1 mg PA Request 4/1/2023 Oncology
J2507 KRYSTEXXA Pegloticase Injection, Pegloticase, 1 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J9047 KYPROLIS Carfilzomib Injection, Carfilzomib, 1 mg PA Request 4/1/2023 Oncology
J0202 LEMTRADA Alemtuzumab Injection, Alemtuzumab, 1 mg PA Request 4/1/2023 Multiple Sclerosis
J1306 LEQVIO Inclisiran Injection, Inclisiran, 1 mg PA Request 4/1/2023 Hypercholesterolemia
J9119 LIBTAYO Cemiplimab-Rwlc Injection, Cemiplimab-rwlc, 1 mg PA Request 4/1/2023 Oncology
J2778 LUCENTIS Ranibizumab Injection, Ranibizumab, 0.1 mg PA Request 4/1/2023 Macular Degeneration
J0221 LUMIZYME Alglucosidase Alfa Injection, Alglucosidase alfa, (lumizyme), 10 mg PA Request 4/1/2023 Enzyme Deficiency
J1950 LUPRON DEPOT Leuoprolide Acetate Injection, Leuprolide acetate (for depot suspension), per 3.75 mg PA Request 4/1/2023 Oncology
J1954  Lutrate
 Leuprolide Acetate Injection, Leuprolide acetate for depot suspension (lutrate), 7.5 mg PA Request 8/1/2023 Oncology
J3398   Luxturna
 Voretigene Neparvovec Injection, Voretigene Neparvovec-rzyl, 1 billion vector genomes PA Request 4/1/2023 Leber Congenital Amaurosis
J2503 MACUGEN Pegaptanib Injection, Pegaptanib sodium, 0.3 mg PA Request 4/1/2023 Macular Degeneration
J1726 MAKENA Hydroxyprogesterone Caproate Injection, Hydroxyprogesterone caproate, (makena), 10 mg PA Request 4/1/2023 Endocrine Disorders
J9349 MONJUVI Tafasitamab-Cxix Injection, Tafasitamab-cxix PA Request 4/1/2023 Oncology
J1437 MONOFERRIC Ferric Derisomaltose Injection, Ferric derisomaltose, 10 mg PA Request 4/1/2023 Anemia
J7327 MONOVISC Hyaluronan Or Derivative Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose PA Request 4/1/2023 Osteoarthritis
 Q5107 Mvasi
 Bevacizumab-Awwb Injection, Bevacizumab-awwb, biosimilar, (mvasi), 10 mg PA Request 8/1/2023 Oncology
J0587 MYOBLOC Rimabotulinumtoxinb Injection, Rimabotulinumtoxinb, 100 units PA Request 4/1/2023 Neurotoxins
 J0220 N/A
  Alglucosidase Alfa Injection, Alglucosidase alfa, 10 mg PA Request 4/1/2023  Enzyme Deficiency
J9044  N/A
 Bortezomib Inj, Bortezomib, nos, 0.1 mg PA Request 4/1/2023  Oncology
J7330  N/A
 MACI implant Autologous Cultured Chondrocytes, implant PA Request 1/1/2023  Osteoarthritis
 Q4082 N/A
 Misc Drug or Biological, not otherwise classified, Part B Drug Competitive Acquisition Program (CAP) PA Request 1/1/2023  Misc
J9314  N/A
 Pemetrexed (Teva) Injection, Pemetrexed (Teva) not therapeutically equivalent to J9305, 10 mg PA Request 8/1/2023  Oncology
 J9048 N/A
 Bortezomib (Fresenius Kabi) Injection, Bortezomib (Fresenius Kabi), not therapeutically equivalent to j9041, 0.1 mg PA Request 8/1/2023  Oncology
 J9049 N/A
 Bortezomib (Hospira) Injection, Bortezomib (Hospira), not therapeutically equivalent to j9041, 0.1 mg PA Request 8/1/2023  Oncology
 J9046 N/A
 Bortezomib (Dr. Reddy's) Injection, Bortezomib, (Dr. Reddy's), not therapeutically equivalent to j9041, 0.1 mg PA Request 8/1/2023  Oncology
 J0893 N/A
 Decitabine (Sun) Injection, Decitabine (Sun Pharma) not therapeutically equivalent to j0894, 1 mg PA Request 8/1/2023  Oncology
 J9394 N/A
 Fulvestrant (Fresnius) Injection, Fulvestrant (Fresenius Kabi) not therapeutically equivalent to j9395, 25 mg PA Request 8/1/2023  Oncology
 J9393 N/A
 Fulvestrant (Teva) Injection, Fulvestrant (Teva) not therapeutically equivalent to j9395, 25 mg PA Request 8/1/2023  Oncology
J1458 NAGLAZYME Galsulfase Injection, Galsulfase, 1 mg PA Request 4/1/2023 Enzyme Deficiency
J2506 NEULASTA Pegfilgrastim, Excludes Biosimilar Injection, Pegfilgrastim, excludes biosimilar, 0.5 mg PA Request 4/1/2023 Neutropenia
J1442 NEUPOGEN Filgrastim (G-Csf), Excludes Biosimilars Injection, Filgrastim (g-csf), excludes biosimilars, 1 microgram PA Request 4/1/2023 Neutropenia
J0219 NEXVIAZYME Avalglucosidase Alfa-Ngpt Injection, Avalglucosidase alfa-ngpt, 4 mg PA Request 4/1/2023 Enzyme Deficiency
 Q5110 Nivestym Filgrastim-Aafi Injection, Filgrastim-aafi, biosimilar, (Nivestym), 1 microgram PA Request 8/1/2023  Neutropenia
 J3490 Not Otherwise Classified Unclassified drugs Drugs Unclassified injection PA Request 4/1/2023  Misc
 J3590 Not Otherwise Classified Unclassified biologics Unclassified Biologics PA Request 1/1/2023  Misc
J2796 NPLATE Romiplostim Injecction, Romiplostim, 10 mg  PA Request 4/1/2023 Thrombocytopenia
J2182 NUCALA Mepolizumab Injection, Mepolizumab, 1 mg PA Request 4/1/2023 Asthma
J0485 NULOJIX Belatacept Injection, Belatacept, 1 mg PA Request 4/1/2023 Immunosuppressive Agents
 Q5122 Nyvepria Pegfilgrastim-Apgf Injection, Pegfilgrastim-apgf (Nyvepria), biosimilar, 0.5 mg PA Request 8/1/2023 Neutropenia
J2350 OCREVUS Ocrelizumab Injection, Ocrelizumab, 1 mg PA Request 4/1/2023 Multiple Sclerosis
J9299 OPDIVO Nivolumab Injection, Nivolumab, 1 mg PA Request 4/1/2023 Oncology
J0129 ORENCIA Abatacept Injection, Abatacept, 10 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J7324 ORTHOVISC Hyaluronan Or Derivative Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose PA Request 4/1/2023 Osteoarthritis
J9306 PERJETA Pertuzumab Injection, Pertuzumab, 1 mg PA Request 4/1/2023 Oncology
J9316 PHESGO Pertuzumab / Trastuzumab / Hyaluronidase-Zzxf Injection, Pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg PA Request 4/1/2023 Oncology
J9204 POTELIGEO Mogamulizumab-Kpkc Injection, Mogamulizumab-kpkc, 1 mg PA Request 4/1/2023 Oncology
J0897 PROLIA Denosumab Injection, Denosumab, 1 mg PA Request 4/1/2023 Osteoporosis
J1301 RADICAVA Edaravone Injection, Edaravone, 1 mg PA Request 1/1/2023 Amyotrophic Lateral Sclerosis
J0896 REBLOZYL Luspatercept-Aamt Injection, Luspatercept-aamt 0.25mg PA Request 4/1/2023 Myelodysplastic Syndrome
J1745 REMICADE Infliximab Injection, Infliximab, excludes biosimilar, 10 mg PA Request 4/1/2023 Auto-inflammatory Conditions
 Q5104 Renflexis Infliximab-Abda Injection, Infliximab-Abda, biosimilar, (Renflexis), 10 mg PA Request 8/1/2023  Auto-Inflammatory Conditions
 Q5123 Riabni Rituximab-Arrx Injection, Rituximab-arrx, biosimilar, (riabni), 10 mg PA Request 8/1/2023  Oncology
J9312 RITUXAN Rituximab Injection, Rituximab, 10 mg PA Request 4/1/2023 Oncology
J9311 RITUXAN HYCELA Rituximab / Hyaluronidase Injection, Rituximab 10 mg and hyaluronidase PA Request 4/1/2023 Oncology
Q5119 Ruxience Rituximab-Pvvr Injection, Rituximab-pvvr, biosimilar, (ruxience), 10 mg  PA Request 8/1/2023 Oncology
J2353 SandoSTATIN LAR Octreotide Injection, Octreotide, Depot Form for Intramuscular Injection, 1 Mg PA Request 4/1/2023 Endocrine Disorders
J1602 SIMPONI ARIA Golimumab Golimumab for iv use 1mg PA Request 4/1/2023 Auto-inflammatory Conditions
J2327  Skyrizi Risankizumab Injection, Risankizumab-Rzaa, intravenous, 1 mg PA Request 8/1/2023 Auto-Inflammatory Conditions
J1300 SOLIRIS Eculizumab Injection, Eculizumab, 10 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J1930 SOMATULINE DEPOT Lanreotide Injection, Lanreotide, 1 mg PA Request 4/1/2023 Endocrine Disorders
J2326 SPINRAZA Nusinersen Injection, Nusinersen, 0.1 mg PA Request 4/1/2023 Spinal Muscular Atrophy
J3358 STELARA IV Ustekinumab Ustekinumab, for intravenous injection, 1 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J3357 STELARA SC Ustekinumab Ustekinumab, for subcutaneous injection, 1 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J1627 SUSTOL Granisetron, Extended-Release Injection, Granisetron, extended-release, 0.1 mg PA Request 4/1/2023 Anti-emetics
J9022 TECENTRIQ Atezolizumab Injection, Atezolizumab,10 mg PA Request 4/1/2023 Oncology
J3241 TEPEZZA Teprotumumab-Trbw Injection, Teprotumumab-trbw, 10 mg PA Request 4/1/2023 Thyroid Eye Disease
J2356 TEZSPIRE Tezepelumab-Ekko Tezepelumab-ekko, 1 mg PA Request 4/1/2023 Asthma
J9033 TREANDA Bendamustine Injection, Bendamustine hcl (treanda), 1 mg PA Request 4/1/2023 Oncology
J3315 TRELSTAR Triptorelin Pamoate Injection, Triptorelin Pamoate 3.75 mg (Trelstar) PA Request 4/1/2023 Oncology
J1628 TREMFYA Guselkumab Injection, Guselkumab, 1 mg PA Request 4/1/2023 Auto-inflammatory Conditions
J7332 TRILURON Hyaluronan Or Derivative Hyaluronan or derivative, Triluron, for intra-articular injection, 1 mg PA Request 4/1/2023 Osteoarthritis
J3316 TRIPTODUR Triptorelin Injection, Triptorelin, extended release 3.75 mg PA Request 4/1/2023 Oncology
J7329 TRIVISC Hyaluronan Or Derivative Hyaluronan or derivative, Trivisc, for intra-articular injection, 1 mg PA Request 4/1/2023 Osteoarthritis
J9317 TRODELVY Sacituzumab Govitecan-Hziy Injection, Sacituzumab Govitecan-Hziy, 2.5 Mg PA Request 4/1/2023 Oncology
Q5115 Truxima
 Rituximab-Abbs Injection, Rituximab-abbs, biosimilar, (Truxima), 10 mg PA Request 8/1/2023 Oncology
J2323 TYSABRI Natalizumab Injection, Natalizumab, 1 mg PA Request 4/1/2023 Multiple Sclerosis
 Q5111 Udenyca Pegfilgrastim-Cbqv  Injection, Pegfilgrastim-cbqv (Udenyca), biosimilar, 0.5 mg  PA Request  8/1/2023 Neutropenia 
J1303 ULTOMIRIS Ravulizumab Injection, Ravulizumab-cwvz, 10 mg PA Request 4/1/2023 Auto-inflammatory Conditions
 J9399 Unclassified Drugs or Biologicals  Chemotherapy Drugs  Chemotherapy Drugs  PA Request   1/1/2023 Oncology 
J1823 UPLIZNA Inebilizumab-Cdon Injection, Inebilizumab-Cdon, 1 Mg PA Request 4/1/2023 Auto-inflammatory Conditions
J9303 VECTIBIX Panitumumab Injection, Panitumumab, 10 mg PA Request 4/1/2023 Oncology
 Q5129 Vegzelma  Bevacizumab-Adcd  Injection, Bevacizumab-adcd (vegzelma), biosimilar, 10 mg  PA Request  8/1/2023  Oncology 
J9041 VELCADE Bortezomib Injection, Bortezomib (velcade), 0.1 mg PA Request 4/1/2023 Oncology
J1427  Viltepso  Viltolarsen  Injection, Viltolarsen, 10 mg  PA Request  1/1/2023  Duchenne Muscular Dystrophy (DMD) 
J3396 VISUDYNE Verteporfin Injection, Verteporfin, 0.1 Mg PA Request 4/1/2023 Ophthalmic Disorders
J3385 VPRIV Velaglucerase Alfa Injection, Velaglucerase alfa, 100 units PA Request 4/1/2023 Enzyme Deficiency
J3032 VYEPTI Eptinezumab Injection, Eptinezumab-jjmr, 1 mg PA Request 4/1/2023 Neurotoxin
 J1429 Vyondys 53  Golodirsen  Injection, Golodirsen, 10 mg  PA Request  1/1/2023  Duchenne Muscular Dystrophy (DMD) 
J0588 XEOMIN Incobotulinumtoxin A Injection, Incobotulinumtoxin a, 1 unit PA Request 4/1/2023 Neurotoxins
J0775 XIAFLEX Collagenase, Clostridium Histolyticum Injection, Collagenase, clostridium histolyticum, 0.01 mg PA Request 4/1/2023 Enzyme
J2357 XOLAIR Omalizumab Injection, Omalizumab, 5 mg PA Request 4/1/2023 Asthma
J9228 YERVOY Ipilimumab Injection, Ipilimumab, 1 mg PA Request 4/1/2023 Oncology
Q5101  Zarxio  Filgrastim-Sndz  Injection, filgrastim-sndz, biosimilar, (Zarxio) 1 microgram  PA Request  8/1/2023  Neutropenia 
J9223 ZEPZELCA Lurbinectedin Injection, Lurbinectedin, 0.1 Mg PA Request 4/1/2023 Oncology
Q5120  Ziextenzo  Pegfilgrastim-Bmez  Injection, Pegfilgrastim-bmez, (Ziextenzo), biosimilar, 0.5 mg  PA Request  8/1/2023  Neutropenia 
J0565 ZINPLAVA Bezlotoxumab Injection, Bezlotoxumab, 10 mg PA Request 4/1/2023 Passive Immunizing and Treatment Agents
 Q5118 Zirabev  Bevacizumab-Bvzr  Injection, Bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg  PA Request  8/1/2023  Oncology 
 J3399 Zolgensma  Onasemnogene abeparvovec  Injection, Onasemnogene Abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes  PA Request  4/1/2023  Spinal Muscular Atrophy 

 

Specialty Drug List
Medical Benefit Specialty Medication Formulary
Specialty drug list
APC Medical Specialty Drug List No PA Required