Lista de autorización previa del 2020 para medicamentos de la parte B de Medicare

Proveedores: Para la respuesta más rápida sobre autorizaciones previas, utilice Availity. Encontrará el enlace de ingreso e instrucciones en la sección de “Usando Availity” de nuestra página de Proveedores.

Miembros: Por lo general, su proveedor se encarga de sus solicitudes de autorización previa. Si necesita ayuda, llámenos al 1-800-338-6833, TTY 711.

Los medicamentos indicados abajo requieren autorización previa. Los medicamentos marcados con un * requieren autorización previa solo cuando se usan para oncología.

Para cada medicamento, proporcionamos el código de facturación, el nombre genérico y el nombre de marca de la siguiente manera:

Código de facturación nombre genérico (NOMBRE DE MARCA)

C Codes

C9053 crizanlizumab-tmca (ADAKVEO)

C9056 givosiran (GIVLAARI)

C9058 pegfilgrastim-bmez, biosimilar (ZIEXTENZO)*

C9257 bevacizumab

C9399 Unclassified drugs or biologicals

J Codes

J0129 abatacept (ORENCIA)

J0178 aflibercept (EYLEA)

J0179 brolucizumab-dbll

J0180 agalsidase beta (FIBRAZYME)

J0185 aprepitant (CINVANTI)*

J0202 alemtuzumab (LEMTRADA)

J0221 alglucosidase alfa (LUMIZYME)

J0222 patisiran (ONPATTRO)

J0256 human alpha 1-proteinase inhibitor (PROLASTIN C, ARALAST NP, ZEMARIA)

J0257 human alpha 1-proteinase inhibitor (GLASSIA)

J0485 belatacept (NULOJIX)

J0490 belimumab (BENLYSTA)

J0517 benralizumab (FASENRA)

J0565 bezlotoxumab (ZINPLAVA)

J0567 cerliponase alfa (BRINEURA)

J0584 burosumab-twza (CRYSVITA)

J0585 onabotulinumtoxinA (BOTOX)

J0586 abobotulinumtoxinA (DYSPORT)

J0587 rimabotulinumtoxinB (MYOBLOC)

J0588 incobotulinumtoxinA (XEOMIN)

J0593 lanadelumab-flyo (TAKHZYRO)

J0594 busulfan (BUSULFEX)*

J0596 recombinant C1 esterase inhibitor (RUCONEST)

J0597 human C1 esterase inhibitor (BERINERT)

J0598 human C1 esterase inhibitor (CINRYZE)

J0599 human C1 esterase inhibitor (HAEGARDA)

J0600 edetate calcium disodium, calcium EDTA

J0630 salmon calcitonin (MIACALCIN)

J0638 canakinumab (ILARIS)

J0640 leucovorin calcium *

J0641 levoleucovorin (FUSILEV, KHAPZORY)*

J0717 certolizumab pegol (CIMZIA)

J0775 collagenase, clostridium histolyticum (XIAFLEX)

J0800 corticotropin, ACTH (H.P. ACTHAR GEL)

J0850 human cytomegalovirus immune globulin intravenous (CYTOGAM)

J0894 decitabine

J0897 denosumab (PROLIA, XGEVA)*

J1260 dolasetron (ANZEMET)*

J1290 ecallantide (KALBITOR)

J1300 eculizumab (SOLIRIS)

J1301 edaravone (RADICAVA)

J1303 ravulizumab-cwvz (ULTOMIRIS)

J1322 elosulfase alfa (VIMIZIM)

J1325 epoprostenol (FLOLAN, VELETRI)

J1428 eteplirsen (EXONDYS)

J1453 fosaprepitant (EMEND)*

J1454 fosnetupitant, palonosetron (AKYNZEO)*

J1458 galsulfase (NAGLAZYME)

J1459 immune globulin (PRIVIGEN)

J1460 immune globulin

J1555 immune globulin (CUVITRU)

J1556 immune globulin (BIVIGAM)

J1557 immune globulin (GAMMAPLEX)

J1559 immune globulin (HIZENTRA)

J1560 immune globulin

J1561 immune globulin (GAMUNEX, GAMUNEX-C, GAMMAKED)

J1562 immune globulin (VIVAGLOBULIN)

J1566 immune globulin

J1568 immune globulin (OCTAGAM)

J1569 immune globulin (GAMMAGARD)

J1572 immune globulin (FLEBOGAMMA, FLEBOGAMMA DIF)

J1575 recombinant hyaluronidase, immune globulin (HYQVIA)

J1599 immune globulin

J1602 golimumab (SIMPONI)

J1626 granisetron (KYTRIL)*

J1627 extended-release granisetron (SUSTOL)*

J1628 guselkumab (TREMFYA)

J1640 hemin (PANHEMATIN)

J1743 idursulfase (ELAPRASE)

J1745 infliximab (REMICADE)

J1786 imiglucerase (CEREZYME)

J1930 lanreotide (SOMATULINE DEPOT)

J1931 laronidase (ALDURAZYME)

J1950 leuprolide acetate for depot suspension (LUPRON DEPOT)*

J2182 mepolizumab (NUCALA)

J2323 natalizumab (TYSABRI)

J2326 nusinersen (SPINRAZA)

J2350 ocrelizumab (OCREVUS)

J2353 octreotide for depot suspension (SANDOSTATIN LAR)

J2357 omalizumab (XOLAIR)

J2469 palonosetron (ALOXI)*

J2502 pasireotide (SIGNIFOR LAR)

J2503 pegaptanib sodium (MACUGEN)

J2505 pegfilgrastim (NEULASTA)*

J2507 pegloticase (KRYSTEXXA)

J2562 plerixafor (MOZOBIL)

J2778 ranibizumab (LUCENTIS)

J2783 rasburicase (ELITEK)*

J2786 reslizumab (CINQAIR)

J2793 rilonacept (ARCALYST)

J2796 romiplostim (NPLATE)

J2797 rolapitant (VARUBI)*

J2820 sargramostim (LEUKINE)*

J2840 sebelipase alfa (KANUMA)

J2860 siltuximab (SYLVANT)*

J3031 fremanezumab-vfrm (AJOVY)

J3060 taliglucerase alpha (ELELYSO)

J3111 romosozumab-aqqg (EVENITY)

J3240 thyrotropin alpha (THYROGEN)*

J3245 tildrakizumab (ILUMYA)

J3262 tocilizumab (ACTEMRA)

J3285 treprostinil (REMODULIN)

J3316 extended-release triptorelin (TRELSTAR, TRIPTODUR)*

J3357 ustekinumab (STELARA)

J3358 ustekinumab (STELARA)

J3380 vedolizumab (ENTYVIO)

J3385 velaglucerase alfa (VPRIV)

J3397 vestronidase alfa-vjbk (MEPSEVII)

J3398 voretigene neparvovec-rzyl (LUXTURNA)

J3590 Unclassified biologics

J3591 Unclassified drug or biological used for ESRD on dialysis

J7170 emicizumab-kxwh (HEMLIBRA)

J7175 human coagulation factor X (COAGADEX)

J7177 human fibrinogen concentrate (FIBRYGA)

J7178 human fibrinogen concentrate

J7179 recombinant von Willebrand factor (VONVENDI)

J7180 human factor XIII concentrate (CORIFACT)

J7181 recombinant coagulation factor XIII A-subunit (TRETTEN)

J7182 turoctocog alfa (NOVOEIGHT)

J7183 von Willebrand factor, human coagulation factor VIII complex (WILATE)

J7185 recombinant antihemophilic factor (XYNTHA)

J7186 antihemophilic factor, human von Willebrand factor complex (ALPHANATE)

J7187 antihemophilic factor, human von Willebrand factor complex (HUMATE-P)

J7188 recombinant antihemophilic factor, porcine sequence (OBIZUR)

J7189 recombinant coagulation factor VIIa (NOVOSEVEN RT)

J7190 human antihemophilic factor (KOATE-DVI)

J7191 porcine antihemophilic factor

J7192 recombinant antihemophilic factor (ADVATE)

J7193 human coagulation factor IX (ALPHANINE SD)

J7194 factor IX complex (BEBULIN)

J7195 recombinant coagulation factor IX (BENEFIX)

J7196 recombinant antithrombin

J7197 human antithrombin III (THROMBATE III)

J7198 anti-inhibitor coagulant complex (FEIBA NF)

J7199 Hemophilia clotting factor, not otherwise classified

J7200 recombinant coagulation factor IX (RIXUBIS)

J7201 recombinant coagulation factor IX (ALPROLIX)

J7202 recombinant antihemophilic factor (IDELVION)

J7203 recombinant glycopegalated coagulation factor IX (REBINYN)

J7205 recombinant antihemophilic factor, Fc fusion protein (ELOCTATE)

J7207 recombinant pegylated antihemophilic factor (ADYNOVATE)

J7208 pegylated lyophilisate antihemophilic factor (JIVI)

J7209 simoctocog alfa (NUWIQ)

J7210 recombinant antihemophilic factor single chain (AFSTYLA)

J7211 recombinant antihemophilic factor (KOVALTRY)

J7313 fluocinolone acetonide (ILUVIEN)

J7318 hyaluronate sodium (DUROLANE)

J7320 hyaluronate sodium (GENVISC)

J7321 hyaluronate sodium (HYALGAN, SUPARTZ, VISCO-3)

J7322 hyaluronic acid (HYMOVIS)

J7323 hyaluronate sodium (EUFLEXXA)

J7324 hyaluronate sodium (ORTHOVISC)

J7325 avian hylan (SYNVISC, SYNVISC-ONE)

J7326 hyaluronate sodium (GEL-ONE)

J7327 hyaluronate sodium (MONOVISC)

J7328 hyaluronate sodium (GELSYN)

J7329 hyaluronate sodium (TRIVISC)

J7331 hyaluronate sodium (SYNOJOINT)

J7332 hyaluronate sodium (TRILURON)

J7639 dornase alfa (PULMOZYME)

J7686 treprostinil (TYVASO)

J7799 NOC drugs, other than inhalation drugs, administered through DME

J8498 Antiemetic drug, rectal/suppository, not otherwise specified

J8501 aprepitant (EMEND)*

J8597 Antiemetic drug, oral, not otherwise specified

J8655 netupitant, palonosetron (AKYNZEO)*

J8670 rolapitant (VARUBI)*

J8999 Prescription drug, oral, chemotherapeutic, NOS

J9000 doxorubicin (ADRIAMYCIN)*

J9015 aldesleukin (PROLEUKIN)*

J9017 arsenic trioxide (TRISENOX)*

J9019 asparaginase - Erwinia chrysanthemi (ERWINAZE)*

J9020 asparaginase*

J9022 atezolizumab (TECENTRIQ)*

J9023 avelumab (BAVENCIO)*

J9025 azacitidine (VIDAZA)*

J9027 clofarabine (CLOLAR)*

J9030 BCG Live (TICE BCG LIVE, THERACYS)*

J9032 belinostat (BELEODAQ)*

J9033 bendamustine (TREANDA)*

J9034 bendamustine (BENDEKA)*

J9035 bevacizumab (AVASTIN)*

J9039 blinatumomab (BLINCYTO)*

J9040 bleomycin sulfate (BLENOXANE, BLEO 15K)*

J9041 bortezomib (VELCADE)*

J9042 brentuximab vedotin (ADCETRIS)*

J9043 cabazitaxel (JEVTANA)*

J9044 bortezomib*

J9045 carboplatin (PARAPLATIN)*

J9047 carfilzomib (KYPROLIS)*

J9050 carmustine (BICNU)*

J9055 cetuximab (ERBITUX)*

J9057 copanlisib (ALIQOPA)*

J9060 cisplatin (PLATINOL, PLATINOL AQ)*

J9065 cladribine (LEUSTATIN)*

J9070 cyclophosphamide (CYTOXAN, NEOSAR)*

J9098 cytarabine liposomal (DEPCYT)*

J9100 cytarabine (CYTOSAR U)*

J9118 calaspargase pegol-mknl (ASPARLAS)*

J9119 cemiplimab-rwlc (LIBTAYO)*

J9120 dactinomycin (COSMEGEN)*

J9130 dacarbazine (DTIC-DOME)*

J9145 daratumumab (DARZALEX)*

J9150 daunorubicin (CERUBIDINE)*

J9151 liposomal daunorubicin (DAUNOXOME)*

J9153 liposomal daunorubicin, liposomal cytarabine (VYXEOS)*

J9155 degarelix (FIRMAGON)*

J9160 denileukin diftitox (ONTAK)*

J9165 diethylstilbestrol (STILPHOSTORL)*

J9171 docetaxel (TAXOTERE)*

J9173 durvalumab (IMFINZI)*

J9175 Injection, Elliotts B solution, 1 ml (Elliotts B Solution)*

J9176 elotuzumab (EMPLICITI)*

J9178 epirubicin (ELLENCE)*

J9179 eribulin (HALAVEN)*

J9181 etoposide (ETOPOPHOS, TOPOSAR, VEPESID)*

J9185 fludarabine (FLUDARA)*

J9190 fluorouracil (ADRUCIL)*

J9199 gemcitabine (INFUGEM)*

J9200 floxuridine (FUDR)*

J9201 gemcitabine (GEMZAR)*

J9202 goserelin (ZOLADEX)*

J9203 gemtuzumab ozogamicin (MYLOTARG)*

J9204 mogamulizumab-kpkc (POTELIGEO)*

J9205 liposomal irinotecan (ONIVYDE)*

J9206 irinotecan (CAMPTOSAR)*

J9207 ixabepilone (IXEMPRA)*

J9208 ifosfamide (IFEX)*

J9209 mesna (MESNEX)*

J9210 emapalumab-lzsg (GAMIFANT)*

J9211 idarubicin (IDAMYCIN)*

J9214 recombinant interferon alfa-2b (INTRON A)*

J9215 human-leukocyte-derived interferon alfa-N3 (ALFERON N)*

J9217 leuprolide acetate for depot suspension (ELIGARD)*

J9218 leuprolide acetate (LUPRON)*

J9219 leuprolide acetate for implant (VIADUR)*

J9225 histrelin (VANTAS)*

J9226 histrelin (SUPPRELIN LA)*

J9228 ipilimumab (YERVOY)*

J9229 inotuzumab ozogamicin (BESPONSA)*

J9230 mechlorethamine (MUSTARGEN)*

J9245 melphalan (ALKERAN)*

J9250 methotrexate*

J9260 methotrexate*

J9261 nelarabine (ARRANON)*

J9262 omacetaxine (SYNRIBO)*

J9263 oxaliplatin (ELOXATIN)*

J9264 albumin-bound paclitaxel (ABRAXANE)*

J9266 pegaspargase (ONCASPAR)*

J9267 paclitaxel (ONXOL, TAXOL)*

J9268 pentostatin (NIPENT)*

J9269 tagraxofusp-erzs (ELZONRIS)*

J9270 plicamycin (MITHRACIN)*

J9271 pembrolizumab (KEYTRUDA)*

J9280 mitomycin (MUTAMYCIN)*

J9285 olaratumab (LARTRUVO)*

J9293 mitoxantrone (NOVANTRONE)*

J9295 necitumumab (PORTRAZZA)*

J9299 nivolumab (OPDIVO)*

J9301 obinutuzumab (GAZYVA)*

J9302 ofatumumab (ARZERRA)*

J9303 panitumumab (VECTIBIX)*

J9305 pemetrexed (ALIMTA)*

J9306 pertuzumab (PERJETA)*

J9307 pralatrexate (FOLOTYN)*

J9308 ramucirumab (CYRAMZA)*

J9309 polatuzumab vendotin-piiq*

J9311 rituximab, hyaluronidase (RITUXAN HYCELA)*

J9312 rituximab, rituximab-abbs (RITUXAN, TRUXIMA)*

J9313 moxetumomab pasudotox-tdfk (LUMOXITI)*

J9315 romidepsin (ISTODAX)*

J9320 streptozocin (ZANOSAR)*

J9325 talimogene laherparepvec (IMLYGIC)*

J9328 temozolomide (TEMODAR)*

J9330 temsirolimus (TORISEL)*

J9340 thiotepa (TEPADINA)*

J9351 topotecan (HYCAMTIN)*

J9352 trabectedin (YONDELIS)*

J9354 ado-trastuzumab emtansine (KADCYLA)*

J9355 trastuzumab (HERCEPTIN)*

J9357 valrubicin (VALSTAR)*

J9360 vinblastine (VELBAN)*

J9370 vincristine (ONCOVIN)*

J9371 liposomal vincristine (MARQIBO)*

J9390 vinorelbine (NAVELBINE)*

J9395 fulvestrant (FASLODEX)*

J9400 ziv-aflibercept (ZALTRAP)*

J9600 porfimer (PHOTOFRIN)*

J9999 Not-otherwise-classified antineoplastic drugs*

Q Codes

Q2017 teniposide (VUMON)*

Q2041 axicabtagene ciloleucel (YESCARTA)*

Q2042 tisagenlecleucel (KYMRIAH)*

Q2043 sipuleucel-T (PROVENGE)*

Q2049 liposomal doxorubicin hydrochloride (LIPODOX, DOXIL)*

Q2050 liposomal doxorubicin hydrochloride (LIPODOX, DOXIL)*

Q3027 interferon beta-1a (AVONEX)

Q3028 interferon beta-1a (REBIF)

Q4074 iloprost (VENTAVIS)

Q5107 bevacizumab-awwb (MVASI)*

Q5108 pegfilgrastim-jmdb (FULPHILA)*

Q5111 pegfilgrastim-cbqv (UDENYCA)*

Q5114 trastuzumab-dkst (OGIVRI)*

Q5116 trastuzumab-qyyp (TRAZIMERA)*

Q5117 trastuzumab-anns (KANJINTI)*

Q5118 bevacizumab-bvcr (ZIRABEV)*