The medications listed below are Specialty Pharmaceuticals ...

1 The medications listed below are Specialty Pharmaceuticals (self-administered) and Medical Drugs (provider administered). Some of these medications may involve unique distribution and may be provided by Presbyterian's Specialty Care pharmacy . Prior Authorization or Medical Exception may be required on some medications , see the listing below for drugs that have this requirement. Unless otherwise noted all medications with an unlisted or unclassified HCPCS code require a Prior Authorization or Medical Exception if the billed charge amount exceeds $ This list is maintained and updated by Presbyterian's pharmacy and Therapeutics Committee. For Provider questions, please contact the Presbyterian pharmacy Call Center at (505)923-5500, or For Member questions, please contact the Presbyterian customer Service Center at (505) 923-5757.

2 Monday through Friday from 8:00 to 5:00 Effective : January 3, 2019. Dispensed Through HCPCS Prior Authorization Route of Brandname Code Description Specialty pharmacy Prior Authorization Exception Notes Other Notes Code or Medical Exception Administration Network 90378 Synagis PALIVIZUMAB IM SOLN 100 MG/ML Prior Auth Yes IM. Radium ra-223 dichloride, therapeutic , per A9606 Xofigo microcurie Med Excep IV. C9014 Brineura Injection, cerliponase alfa, 1 mg Med Excep Code Effective: 01-01-2018 Intraventricular Injection, c-1 esterase inhibitor (human), C9015 Haegarda haegarda, 10 units Med Excep Code Effective: 01-01-2018 SC. Injection, triptorelin extended release, C9016 Triptodur mg Med Excep Code Effective: 01-01-2018 IM.

3 Injection, liposomal, 1 mg daunorubicin and C9024 Vyxeos mg cytarabine Prior Auth Code Effective: 01-01-2018 IV. C9028 Besponsa Injection, inotuzumab ozogamicin, mg Prior Auth Code Effective: 01-01-2018 IV. C9029 Tremfya Injection, guselkumab, 1 mg Med Excep Code Effective: 01-01-2018 SC. New Code Effective: C9030 Aliqopa Injection, copanlisib, 1 mg Prior Auth 07/01/2018 IV. Lutetium Lu 177, dotatate, therapeutic , 1 New Code Effective: C9031 Lutathera mCi Med Excep 07/01/2018 IV. Injection, voretigene neparvovec-rzl, 1 billion New Code Effective: C9032 Luxturna vector genome Med Excep 07/01/2018 Intraocular PPC021101 1. Dispensed Through HCPCS Prior Authorization Route of Brandname Code Description Specialty pharmacy Prior Authorization Exception Notes Other Notes Code or Medical Exception Administration Network C9033 only for Medicare Hospital Outpatient.

4 Use Injection, fosnetupitant 235mg and J3490 for all other billing. New C9033 Akynzeo palonestron Med Excep Code Effective: 10/01/2018 IV. Injection, dexamethasone 9%, intraocular, 1 New Code Effective: C9034 Dexycu mcg Med Excep X 10/01/2018 Intraocular C9113 Protonix PANTOPRAZOLE SODIUM, PER VIAL No IV. Prothrombin complex concentrate (human), C9132 Kcentra kcentra, per of factor ix activity No New Code effective 10/1/13 IV. C9248 Cleviprex CLEVIDIPINE BUTYRATE, 1 MG No IV. C9254 Vimpat LACOSAMIDE, 1 MG No IV. PPC021101 2. Dispensed Through HCPCS Prior Authorization Route of Brandname Code Description Specialty pharmacy Prior Authorization Exception Notes Other Notes Code or Medical Exception Administration Network No prior authorization needed when billed with one of the following diagnosis codes : , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , - , H32, , , , , , , , , , , , , , , , C9257 Avastin BEVACIZUMAB, MG Prior Auth , Prior Auth effective 01/01/11 IV.

5 C9275 Cysview hexaminolevulinate hydrochloride, 100 mg No Code effective 01/01/2011. C9290 Exparel Bupivacaine liposome, 1mg, injection No New Code effective 04/01/12. New code effective 10/01/12, C9293 Voraxaze Glucarpidase injection, IV Med Excep Yes Medical Exception 05/12 P&T IV. C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS Med Excep Injection, phenylephrine and ketorolac, 4 ml add to irrigation C9447 Omidria vial No New Code Effective 1/1/15 soln PPC021101 3. Dispensed Through HCPCS Prior Authorization Route of Brandname Code Description Specialty pharmacy Prior Authorization Exception Notes Other Notes Code or Medical Exception Administration Network C9460 Kengreal Injection, cangrelor, 1 mg Yes New Code Effective 1/01/16 IV.

6 C9462 Baxdela Injection, delafloxacin, 1 mg Med Excep New Code Effective 4/01/18 IV. C9463 only for Medicare Hospital Outpatient. Use J3490 for all other billing. C9463 Cinvanti Injection, aprepitant, 1 mg Med Excep New Code Effective 4/01/18 IV. C9464 Varubi Injection, rolapitant, mg Med Excep New Code Effective 4/01/18 IV. hyaluronan or derivative, Durolane, for itra- C9465 Durolane articular injection, per dose Med Excep Yes New Code Effective 4/01/18 intra-articular C9466 Fasenra Injection, benralizumab, 1 mg Med Excep Yes New Code Effective 4/01/18 SQ. Injection, rituximab and hyaluronidase, 10. C9467 RituxanHycela mg Med Excep New Code Effective 4/01/18 IV. Injection, Factor IX (antihemophilic factor, C9468 Rebinyn recombinant), glycopegylated, Rebinyn, 1 IU Med Excep Yes New Code Effective 4/01/18 IV.

7 C9482 Injection, sotalol hydrochloride, 1 mg Med Excep New code effective 10/01/2016 IV. New code effective: C9488 Vaprisol Injection, conivaptan hydrochloride, 1 mg Med Excep 04-01-2017 IV. New code effective: 10-01-2017. OPPS pass through status (can only be reimbursed from C9492 Imfinzi Injection, durvalumab, 10 mg Med Excep an outpatient facility) IV. New code effective: 10-01-2017. OPPS pass through status (can only be reimbursed from C9493 Radicava Injection, edaravone, 1 mg Med Excep an outpatient facility) IV. C9497 ADUSAVE LOXAPINE, INHALATION POWDER, 10 MG Med Excep New code effective 01/01/14 Inhalation J0120 TETRACYCLINE, UP TO 250 MG No IM, IV, IP. J0129 : Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self J0129 Orencia administered) Prior Auth Yes IV.

8 J0130 Reopro INJECTION ABCIXIMAB, 10 MG No IV. PPC021101 4. Dispensed Through HCPCS Prior Authorization Route of Brandname Code Description Specialty pharmacy Prior Authorization Exception Notes Other Notes Code or Medical Exception Administration Network J0131 Ofirmev ACETAMINOPHEN IV SOLN 10 MG/ML No New code effective 01/01/2012 IV. J0132 Acetadote ACETYLCYSTEINE, 100 MG No IV. J0133 Acyclovir ACYCLOVIR, 5 MG No IV. J0135 Humira ADALIMUMAB, 20 MG Prior Auth Yes SC. Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate J0153 compounds) No New code effective 01/01/2015 IV. J0171 Adrenalin adrenalin, epinephrine, No New code effective 1/1/2011. AFLIBERCEPT INJECTION 1MG New code effective 01/01/13 , J0178 Eylea INTRAVITREAL No Yes Medical Excep removed 5/1/13 Intravitreal Specialty Network Effective J0180 Fabrazyme AGALSIDASE BETA, 1 MG Med Excep Yes 10/1/13, Med Excep 10/1/13 IV.

9 J0190 BIPERIDEN LACTATE, PER 5 MG No IM, IV. J0200 ALATROFLOXACIN MESYLATE, 100 MG No IV. J0202 Lemtrada Injection, alemtuzumab, 1 mg Medical Excep New Code Effective 1/01/16 IV. Specialty Network Effective J0205 Ceredase ALGLUCERASE, PER 10 UNITS Med Excep Yes 10/1/13, Med Excep 10/1/13 IV. Prior Auth effective 01/01/2011, Specialty Network J0207 Ethyol AMIFOSTINE, 500 MG Prior Auth Yes effective 10/1/13 IV. J0210 Methyldopate METHYLDOPATE HCL, UP TO 250 MG No IV. Specialty Network Effective J0215 Amevive ALEFACEPT, MG Med Excep Yes 10/1/13 IM. Specialty Network Effective J0220 Myozyme ALGLUCOSIDASE ALFA, 10 MG Med Excep Yes 10/1/13 IV. New code effective 01/01/2012, Specialty Network J0221 Lumizyme Alglucosidase alfa IV, 10mg Med Excep Yes Effective 10/1/13 IV.

10 Aralast, Prolastin, ALPHA 1 - PROTEINASE INHIBITOR - Specialty Network Effective J0256 Zemaira HUMAN, 10 MG Med Excep Yes 10/1/13 IV. New code effective Injection, alpha 1 proteinase inhibitor 01/01/2012, Specialty Network J0257 Glassia (human), (Glassia), 10 mg (IV) Med Excep Yes Effective 10/1/13 IV. PPC021101 5. Dispensed Through HCPCS Prior Authorization Route of Brandname Code Description Specialty pharmacy Prior Authorization Exception Notes Other Notes Code or Medical Exception Administration Network ALPROSTADIL, MCG (CODE MAY BE. USED FOR MEDICARE WHEN DRUG. ADMINISTERED UNDER THE DIRECT. SUPERVISION OF A PHYSICIAN, NOT. FOR USE WHEN DRUG IS SELF INTRACAVERNO. J0270 Caverject ADMINISTERED) Med Excep Yes USLY.