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HCPCS codesBrand nameGeneric nameHCPCS DescriptionRequirementRequirement effective dateClinical Category
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J9264ABRAXANEpaclitaxelInjection, paclitaxel protein-bound particles, 1 mgPrecertification Notification1/1/2021Oncology
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J3262ACTEMRAtocilizumabINJECTION, TOCILIZUMAB, 1 MGPA Request1/1/2023Auto-inflammatory Conditions
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J0800ACTHARcorticotropinInjection, corticotropin, up to 40 unitsPrecertification Notification1/1/2021Endocrine Disorders
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J2504ADAGENpegademase bovineInjection, pegademase bovine, 25 iuPrecertification Notification1/1/2021Enzyme Deficiency
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J0791ADAKVEOcrizanlizumab-tmcaInj crizanlizumab-tmca 5 mgPA Request1/1/2023Sickle Cell Disease
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J9042ADCETRISbrentuximabBrentuximab Vedotin, 1mgPA Request1/1/2023Oncology
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J9000ADRIAMYCINdoxorubicin hclInjection, doxorubicin hydrochloride, 10 mgPrecertification Notification1/1/2021Oncology
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J9190ADRUCILfluorouracilInjection, fluorouracil, 500 mgPrecertification Notification1/1/2021Oncology
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J0172ADUHELMaducanumab-avwaInjection, aducanumab-avwa, 2 mgExclusion: Medical Necessity Review Required1/1/2022Antidementia Agent
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J7192ADVATEfactor viiiFactor viii (antihemophilic factor, recombinant) per i.u., not otherwise specifiedPrecertification Notification1/1/2021Hemophilia
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J7207ADYNOVATEfactor viiiInjection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u.Precertification Notification1/1/2021Hemophilia
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J7210AFSTYLAfactor viiiInjection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u.Precertification Notification1/1/2021Hemophilia
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J1454AKYNZEOfosnetupitant / palonosetronInjection, fosnetupitant 235 mg and palonosetron 0.25 mgPrecertification Notification8/1/2022Anti-emetics
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J1931ALDURAZYMElaronidaseInjection, laronidase, 0.1 mgPrecertification Notification1/1/2021Enzyme Deficiency
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J9215ALFERON Ninterferon, alfa-n3, (human leukocyte derived)Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iuPrecertification Notification1/1/2021Oncology
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J0220Alglucosidase alfaAlglucosidase alfaInjection, alglucosidase alfa, 10 mg, not otherwise specifiedPA Request10/1/2022Enzyme Deficiency
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J9305ALIMTApemetrexedInjection, pemetrexed, not otherwise specified, 10 mgPrecertification Notification1/1/2021Oncology
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J9057ALIQOPAcopanlisibInj., copanlisib, 1 mgPA Request1/1/2023Oncology
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J9245ALKERANmelphalan hclInjection, melphalan hydrochloride, not otherwise specified, 50 mgPrecertification Notification1/1/2021Oncology
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J2469AloxiPalonosetron hclInjection, palonosetron hcl, 25 mcgNo PA/No Precert RequiredN/AAnti-emetics
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J7186ALPHANATEfactor viii/von willebrand factorInjection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u.Precertification Notification1/1/2021Hemophilia
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J7193ALPHANINE SDfactor ixFactor ix (antihemophilic factor, purified, non-recombinant) per i.u.Precertification Notification1/1/2021Hemophilia
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J7201ALPROLIXfactor ixInjection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.Precertification Notification1/1/2021Hemophilia
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J7345AMELUZaminolevulinic acid hclAminolevulinic acid hcl for topical administration, 10% gel, 10 mgPrecertification Notification1/1/2021Actinic Keratosis
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J0225AmvuttraVutrisiranInjection, vutrisiran, 1 mgNot Covered5/1/23Neurotoxins
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J0739ApretudeCabotegravirInjection, cabotegravir, 1 mgPrecertification Notification5/1/23HIV/AIDS
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J0256ARALAST NPalpha 1 proteinase inhibitorInjection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mgPrecertification Notification1/1/2021Enzyme Deficiency
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J0881ARANESPdarbepoetin alfaInjection, darbepoetin alfa, 1 microgram (non-esrd use)Precertification Notification1/1/2021Anemia
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J2430ArediaPamidronate disodiumInjection, pamidronate disodium, per 30 mgNo PA/No Precert RequiredN/AOsteoporosis
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J9261ARRANONnelarabineInjection, nelarabine, 50 mgPrecertification Notification1/1/2021Oncology
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J9017ARSENIC TRIOXIDEarsenic trioxideInjection, arsenic trioxide, 1 mgPrecertification Notification1/1/2021Oncology
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J9302ARZERRAofatumumabINJECTION, OFATUMUMAB, 10 MGPA Request1/1/2023Oncology
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90283ASCENIVimmune globulinImmune globulin (IgIV), human, for intravenous usePrecertification Notification1/1/2021Immunodeficiency
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J1554ASCENIVimmune globulinInjection, immune globulin (asceniv), 500 mgPrecertification Notification1/1/2021Immunodeficiency
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J9118ASPARLAScalaspargase pegol-mknlInjection, calaspargase pegol-mknl, 10 unitsPrecertification Notification1/1/2021Oncology
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J7196ATRYNantithrombinInjection, antithrombin recombinant, 50 i.u.Precertification Notification1/1/2021Hereditary Antithrombin Deficiency
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J9035AVASTINbevacizumabInjection, bevacizumab, 10 mgPA Request8/1/2022Oncology
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J9035AVASTINbevacizumabInjection, bevacizumab, 10mgNo PA required8/1/2022Ophthalmic Disorders
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J3145AVEEDtestosterone undecanoateInjection, testosterone undecanoate, 1 mgPrecertification Notification1/1/2021Endocrine Disorders
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Q5121AvsolaInfliximab-axxqInjection, infliximab-axxq, biosimilar, (avsola), 10 mgNo PA/No Precert RequiredN/AAuto-inflammatory Conditions
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J9025AZACITIDINEazacitidineInjection, azacitidine, 1 mgPrecertification Notification1/1/2021Oncology
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J9023BAVENCIOavelumabInjection, avelumab, 10 mgPrecertification Notification1/1/2021Oncology
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90585BCG VACCINEbcg liveBacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous usePrecertification Notification1/1/2021Oncology/vaccine
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J9032BELEODAQbelinostatInjection, belinostat, 10 mgPrecertification Notification1/1/2021Oncology
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J9036BELRAPZObendamustine hclInjection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mgPrecertification Notification1/1/2021Oncology
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J9036BENDAMUSTINE HCLbendamustine hclInjection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mgPrecertification Notification1/1/2021Oncology
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J9034BENDEKAbendekaInjection, bendamustine hcl (bendeka), 1 mgPrecertification Notification1/1/2021Oncology
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J7195BENEFIXfactor ixInjection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specifiedPrecertification Notification1/1/2021Hemophilia
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J0490BENLYSTA IVbelimumabInjection, belimumab, 10 mgPA Request1/1/2023Systemic Lupus Erythematosus (SLE)
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J0179BEOVUBrolucizumabInjection, brolucizumab-dbll, 1 mgPA Request10/1/2022Macular Degeneration
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J0597BERINERTc1 esterase inhibitorInjection, c-1 esterase inhibitor (human), berinert, 10 unitsPrecertification Notification1/1/2021Hereditary Angioedema
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J9229BESPONSAinotuzumab ozogamicinInjection, inotuzumab ozogamicin, 0.1 mgPA Request1/1/2023Oncology
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Q5126Bevacizumab (Alymsys)Bevacizumab-malyInjection, bevacizumab-maly, biosimilar, (alymsys), 10 mgNo PA/No Precert RequiredN/AOncology
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Q5118Bevacizumab (Zirabev)Bevacizumab-bvzrInjection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mgNo PA/No Precert RequiredN/AOncology
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Q5107Bevacizumab (Mvasi)Bevacizumab-awwbInjection, bevacizumab-awwb, biosimilar, (mvasi), 10 mgNo PA/No Precert RequiredN/AOncology
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Q5129Bevacizumab (Vegzelma)Bevacizumab-adcdInjection, bevacizumab-adcd (vegzelma), biosimilar, 10 mgNo PA/No Precert RequiredN/AOncology
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J9050BICNUcarmustineInjection, carmustine, 100 mgPrecertification Notification1/1/2021Oncology
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90283BIVIGAMimmune globulinImmune globulin (IgIV), human, for intravenous usePrecertification Notification1/1/2021Immunodeficiency
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J1556BIVIGAMimmune globulinInjection, immune globulin (bivigam), 500 mgPrecertification Notification1/1/2021Immunodeficiency
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J9037BLENREPbelantamab mafodotin-blmfInjection, belantamab mafodotin-blmf, 0.5 mgPrecertification Notification1/1/2021Oncology
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J9040BLEOMYCIN SULFATEbleomycin sulfateInjection, bleomycin sulfate, 15 unitsPrecertification Notification1/1/2021Oncology
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J9039BLINCYTOblinatumomabInjection, blinatumomab, 1 microgramPA Request1/1/2022Oncology
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J1740BonivaIbandronate sodiumInjection, ibandronate sodium, 1 mgNo PA/No Precert RequiredN/AOsteoporosis
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J9046Bortezomib (Velcade Biosimilar)BortezomibInjection, bortezomib, (dr. reddy's), not therapeutically equivalent to j9041, 0.1 mg ((biosimilar for VELCADE)No PA/No Precert RequiredN/AOncology
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J9048Bortezomib (Velcade Biosimilar)BortezomibInjection, bortezomib (fresenius kabi), not therapeutically equivalent to j9041, 0.1 mg (biosimilar for VELCADE)No PA/No Precert RequiredN/AOncology
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J9049Bortezomib (Velcade Biosimilar)BortezomibInjection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg (biosimilar for VELCADE)No PA/No Precert RequiredN/AOncology
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J0585BOTOXonabotulinumtoxinaInjection, onabotulinumtoxina, 1 unitPA Request6/1/2022Neurotoxins
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J0567BRINEURAcerliponase alfaInjection, cerliponase alfa, 1 mgPA Request1/1/2022Enzyme Deficiency
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J0594BUSULFANbusulfaninjection, busulfan, 1 mgPrecertification Notification1/1/2021Oncology
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Q5124ByoovizRanibizumab-nunaInjection, ranibizumab-nuna, biosimilar, (byooviz)No PA/No Precert RequiredN/AMacular Degeneration
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J9206CAMPTOSARirinotecanInjection, irinotecan, 20 mgPrecertification Notification1/1/2021Oncology
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J9045CARBOPLATINcarboplatinInjection, carboplatin, 50 mgPrecertification Notification1/1/2021Oncology
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J9050CARMUSTINEcarmustineInjection, carmustine, 100 mgPrecertification Notification1/1/2021Oncology
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J2724CEPROTINprotein c concentrate, IV, humanInjection, protein c concentrate, intravenous, human, 10 iuPrecertification Notification1/1/2021Severe Congenital Protein C Deficiency
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J1786CEREZYMEImiglucerase Injection, imiglucerase, 10 unitsPA Request10/1/2022Enzyme Deficiency
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J0740CIDOFOVIRcidofovirInjection, cidofovir, 375 mgPrecertification Notification1/1/2021Anti-Infective Therapy
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J0717CIMZIAcertolizumabCertolizumab pegol inj 1mgPA Request1/1/2023Auto-inflammatory Conditions
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J2786CINQAIRreslizumabInjection, reslizumab, 1 mgPA Request8/1/2022Asthma
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J0598CINRYZEc1 esterase inhibitorInjection, c-1 esterase inhibitor (human), cinryze, 10 unitsPrecertification Notification1/1/2021Hereditary Angioedema
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J9060CISPLATINcisplatinInjection, cisplatin, powder or solution, 10 mgPrecertification Notification1/1/2021Oncology
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J9065CLADRIBINEcladribineInjection, cladribine, per 1 mgPrecertification Notification1/1/2021Oncology
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J9027CLOFARABINEclofarabineInjection, clofarabine, 1 mgPrecertification Notification1/1/2021Oncology
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J9027CLOLARclofarabineInjection, clofarabine, 1 mgPrecertification Notification1/1/2021Oncology
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J7175COAGADEXfactor xInjection, factor x, (human), 1 i.u.Precertification Notification1/1/2021Hemophilia
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J7180CORIFACTfactor xiiiInjection, factor xiii (antihemophilic factor, human), 1 i.u.Precertification Notification1/1/2021Hemophilia
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J9120COSMEGENdactinomycinInjection, dactinomycin, 0.5 mgPrecertification Notification1/1/2021Oncology
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J0584CRYSVITAburosumabInjection, burosumab-twza 1 mgPA Request1/1/2023Metabolic Conditions
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J1551CUTAQUIGimmune globulin (cutaquig)Injection, immune globulin (cutaquig), 100 mgNot Covered7/1/2022Immunodeficiency
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90284CUVITRUimmune globulinImmune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, eachPrecertification Notification1/1/2021Immunodeficiency
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J1555CUVITRUimmune globulinInjection, immune globulin (cuvitru), 100 mgPrecertification Notification1/1/2021Immunodeficiency
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J9070CYCLOPHOSPHAMIDEcyclophosphamideCyclophosphamide, 100 mgPrecertification Notification1/1/2021Oncology
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J9071CYCLOPHOSPHAMIDEcyclophosphamideInjection, cyclophosphamide, (auromedics), 5 mgPrecertification Notification8/1/2022Oncology
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J9308CYRAMZAramucirumabInjection, ramucirumab, 5 mgPA Request1/1/2023Oncology
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J9100CYTARABINEcytarabineInjection, cytarabine, 100 mgPrecertification Notification1/1/2021Oncology
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J1570CYTOVENEganciclovir sodiumInjection, ganciclovir sodium, 500 mgPrecertification Notification1/1/2021Anti-Infective Therapy
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J9130DACARBAZINEdacarbazineDacarbazine, 100 mgPrecertification Notification1/1/2021Oncology
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J0894DACOGENdecitabineInjection, decitabine, 1 mgPrecertification Notification1/1/2021Oncology
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J9120DACTINOMYCINdactinomycinInjection, dactinomycin, 0.5 mgPrecertification Notification1/1/2021Oncology
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J9348DANYELZAnaxitamab-gqgkInjection, naxitamab-gqgk, 1 mgPA Request1/1/2022Oncology