508C, Provider-Administered Specialty Pharmacy Products

1 SM. BlueCare TennCareSelect CoverKids . Provider-Administered Specialty Pharmacy Products The drugs on the list below need to be ordered by a provider and administered in an office or outpatient setting. For medications that need prior authorization, providerscan: . Log in to Availity . - Select the Tennessee region, and then select Payer Space.. - Click the Authorization Submission/Review application. - Select SpecialtyPharmacy.. Call 1-800-924-7141 for Commercial members. Call 1-888-423-0131 for BlueCare members. Call 1-800-711-4104 for TennCareSelect members. Call 1-800-924-7141 for CoverKids members. HCPCS Code Drug Name HCPCS Code Drug Name HCPCS Code Drug Name J0401 Abilify Maintena J0598 CinryzePA J1566 Gammagard S-D (powder)PA. PA. J9264 Abraxane J0584 CrysvitaPA J1561 GammakedPA. J3262 ActemraPA J1555 CuvitruPA J1557 GammaplexPA. J0800 Acthar GelPA J9308 CyramzaPA J1561 Gamunex-CPA. PA. J2504 Adagen J0850 Cytogam J9301 GazyvaPA.

2 J9042 AdcetrisPA J1570 Cytovene IV J7326 Gel-OnePA. J1454 Akynzeo PA J0894 Dacogen J7328 Gel-SynPA. PA PA. J1931 Aldurazyme J9145 Darzalex J9201 Gemzar PA. J9215 Alferon N J7318 Durolane J7320 GenviscPA. PA PA. J9305 Alimta J0586 Dysport J0257 GlassiaPA. J9057 AliqopaPA J1743 ElaprasePA J1447 Granix PA PA. J2469 Aloxi J3060 Eleyso J0599 HaegardaPA. PA PA. J0256 Aralast NP J9217 Eligard IM J9179 HalavenPA. J0882 AranespPA (ESRD on dialysis) J9176 EmplicitiPA J9355 HerceptinPA. PA PA. J0881 Aranesp (non-ESRD) J3380 Entyvio J1559 HizentraPA. J1942 Aristada Q4081 EpogenPA (ESRD on dialysis) J7321 HyalganPA. J9261 ArranonPA J0885 EpogenPA (non-ESRD) J9351 Hycamtin IV. PA PA. J9302 Arzerra J1325 Epoprostenol J7322 HymovisPA. J9035 AvastinPA J9055 ErbituxPA J2790 HyperRHO S-D. PA. J9023 Bavencio J9019 Erwinaze J1575 HyQviaPA. J9032 BeleodaqPA J7323 EuflexxaPA J0638 IlarisPA. J9034 BendekaPA J9245 Evomela J3245 IlumyaPA.

3 PA PA. J0490 Benlysta J1428 Exondys 51 J7313 IluvienPA. J0597 BerinertPA J0178 EyleaPA J9173 ImfinziPA. PA PA. J9229 Besponsa J0180 Fabrazyme J9325 ImlygicPA. J1556 BivigamPA J0517 FasenraPA Q5103 InflectraPA. J9039 BlincytoPA J1744 FirazyrPA J2426 Invega Sustenna PA PA. J9044 Bortezomib J9155 Firmagon J2426 Invega Trinza PA PA. J0585 Botox J1572 Flebogamma J0567 BrineuraPA J1325 FlolanPA. J9206 Camptosar J9307 FolotynPA. J1566 Carimune NFPA Q5108 FulphilaPA. PA. J1786 Cerezyme J0641 FusilevPA. J0717 Cimzia vialsPA J1560 Gamastan S-D. J2786 CinqairPA J1569 Gammagard LiquidPA. HCPCS Code Drug Name HCPCS Code Drug Name HCPCS Code Drug Name J9315 Istodax PA. J1599 Panzyga PA J3490 TegsediPA. J9207 IxempraPA J9306 PerjetaPA J9328 Temodar PA. PA PA. J7316 Jetrea J9999 Poteligeo S0189 TestopelPA. J9043 JevtanaPA J9295 PortrazzaPA J3240 ThyrogenPA. PA. J9354 Kadcyla J2278 Prialt J9351 Topotecan PA PA. J1290 Kalbitor J1459 Privigen J9330 ToriselPA.

4 J2840 KanumaPA Q4081 ProcritPA (ESRD on dialysis) J9033 TreandaPA. PA PA. J9271 Keytruda J0885 Procrit (non-ESRD) J3315 TrelstarPA. Q5111 KhapzoryPA J0256 Prolastin CPA J3316 TriptodurPA. PA. J2507 Krystexxa J9015 ProleukinPA J9017 Trisenox PA PA. Q2042 *Kymriah J0897 Prolia J7329 TriViscPA. J9047 KyprolisPA Q2043 ProvengePA J1746 Trogarzo PA. PA. J9285 Lartruvo J7336 Qutenza J2323 TysabriPA. J0202 LemtradaPA J1301 RadicavaPA J7686 TyvasoPA. J2820 Leukine PA. J3489 Reclast PA. J3490 UdenycaPA. J9999 LibtayoPA J1745 RemicadePA J9999 Unituxin PA. J2778 Lucentis J3285 Remodulin PA. J9225 VantasPA. PA. J0221 Lumizyme Q5104 RenflexisPA J9303 VectibixPA. J9999 LumoxitiPA Q5105 RetacritPA (ESRD on dialysis) J9041 VelcadePA. J1950 Lupron DepotPA (endocrine use) Q5106 RetacritPA (non-ESRD) J1325 VeletriPA. PA. J9217 Lupron Depot (antineoplastic use) J7311 Retisert PA. J9025 VidazaPA. J3398 LuxturnaPA J3590 RevcoviPA J1322 VimizimPA.

5 PA. J2503 Macugen J2788 RhoGAM Ultra-Filtered Plus J7321 Visco-3PA. J1726 Makena J2791 Rhophylac J0740 Vistide J9371 Marqibo PA. J7178 RiaSTAP J3396 VisudynePA. PA. J3397 Mepsevii J2794 Risperdal Consta J2315 Vivitrol PA. J2788 MICRhoGAM Ultra-Filtered Plus J9312 Rituxan J3385 VPRIVPA. PA PA. J0887 Mircera (ESRD on dialysis) J9311 Rituxan Hycela J9153 VyxeosPA. J0888 MirceraPA (non-ESRD) J0596 RuconestPA J2792 WinRho SDF. PA PA. J7327 Monovisc J2353 Sandostatin LAR J0588 XeominPA. PA. J2562 Mozobil J2502 Signifor LAR J0897 XgevaPA. J9203 MylotargPA J1602 Simponi AriaPA J0775 XiaflexPA. PA PA. J0587 Myobloc J1300 Soliris J2357 XolairPA. J1458 NaglazymePA J1930 Somatuline DepotPA J9228 YervoyPA. J2505 NeulastaPA J2326 SpinrazaPA Q2041 *YescartaPA. PA. J1442 Neupogen J3358 Stelara IV J9352 YondelisPA. Q5110 Nivestym J3357 Stelara SCPA J3490 YutiqPA. PA. J7189 NovoSeven RT J7321 Supartz J9400 ZaltrapPA.

6 J2796 NplatePA J9226 Supprelin LAPA Q5101 Zarxio PA PA. J2182 Nucala J1627 Sustol J0256 ZemairaPA. PA PA. J2350 Ocrevus J2860 Sylvant J9202 ZoladexPA. PA PA. J1568 Octagam 90378 Synagis J3489 ZometaPA. PA PA. J9205 Onivyde J3490 Synojoynt J2358 Zyprexa Relprevv PA PA. J3490 Onpattro J9262 Synribo PA. J9299 Opdivo J7325 SynviscPA. PA. J0129 Orencia IV J7325 Synvisc-OnePA. PA. J7324 Orthovisc J3590 TakhzyroPA. J7312 OzurdexPA J9022 TecentriqPA. PA. Requires a Prior Authorization * Also requires an inpatient authorization 1 Cameron Hill Circle Chattanooga, TN 37402 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association 18 PED291102(4/19) provider administered Specialty List