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Navigated to 2020 Prior Authorization List for Medicare Part B Drugs page

2020 Prior Authorization List for Medicare Part B Drugs


Providers: For the quickest turnaround on prior authorizations, use Availity. You can find the login link and instructions in the "Using Availity" section of our Providers page.

Members: Your provider usually handles prior authorizations for you. If you need any help, call us at 1-800-338-6833, TTY 711.

The drugs listed below require prior authorization. Drugs marked with a * require prior authorization only when used for oncology.

For each drug, we provide the billing code, generic name, and brand name as follows:

Billing Code Generic Name (Brand Name)

C Codes

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)

J3490  Unclassified drugs

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  glycopegylated coagulation factor IX (REBINYN)

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)

J7699  NOC drugs, inhalation solution administered through DME

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

J7999  Compounded drug, not otherwise classified

J8498  Antiemetic drug, rectal/suppository, not otherwise specified

J8499  Prescription drug, oral, nonchemotherapeutic, NOS

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)*

J9031  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)*

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)*

Q5114  trastuzumab-dkst (OGIVRI)*

Q5116  trastuzumab-qyyp (TRAZIMERA)*

Q5117  trastuzumab-anns (KANJINTI)*

Q5118  bevacizumab-bvcr (ZIRABEV)*