• Bone graft substitutes and bone morphogenetic proteins for spine surgery 
• Cervical decompression with or without fusion cervical disc arthroplasty 
• Hip arthroplasty 
  
• Hip arthroscopy and open procedures 
• Knee arthroplasty
  
• Knee arthroscopy and open procedures 
• Lumbar disc arthroplasty 
• Lumbar discectomy, foraminotomy, and laminotomy 
• Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis) 
• Lumbar laminectomy 
• Meniscal allograft transplantation of the knee 
• Shoulder arthroplasty 
• Shoulder arthroscopy and open procedures 
• Treatment of osteochondral defects 
• ​Vertebroplasty/Kyphoplasty 

Interventional pain manageme​​nt services

Precertification is performed by AIM Specialty Health®. For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.  

• Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
  
• Paravertebral Facet Injection/Nerve Block/Neurolysis 
• Regional Sympathetic Nerve Block 
• Sacroiliac joint injections 
• ​Implanted spinal cord stimulators 

Reconstructive procedures and poten​​tially cosmetic procedures 

• Blepharoplasty/ptosis repair
  
  15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909​ 


• ​Bone graft, genioplasty and mentoplasty
  
  21120, 21121, 21122, 21123
   
• Breast Reconstruction
  
  11920, 11921, 11922, 11970, 11971, 15271, 15272, 15769, 15771, 15772, 15773, 15774, 15777, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4100, Q4107, Q4130, S2066, S2067, S2068
   
• Breast Reduction
  
  15877, 19318
   
• Breast Augmentation/Mammoplasty
  
  19325​
   
• Breast Mastopexy
  
  19316
   
• Insertion of Breast Implants
  
  19340, 19342, 19396
   
• Removal of Breast Implants
  
  19328, 19330, 19370, 19371
   
• Canthopexy/Canthoplasty
  
  21280, 21282, 67950
   
• Cervicoplasty
  
  15819
   
• Chemical peels
  
  15788, 15789, 15792, 15793​
   
• Dermabrasion
  
  15780, 15781, 15782, 15783
   
• Excision of excessive skin and/or subcutaneous tissue
  
  15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839
   
• Gender reassignment surgery
  
  11960, 19303, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
   
• Genetically and bio-engineered skin substitutes for wound care
  
  C1849, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4227, Q4228, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4244, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4254, Q4255
   
• Hair transplant
  
  15775, 15776
   
• Injectable dermal fillers
  
  11950, 11951, 11952, 11954, Q2026, Q2028
   
• Keloid removal
  
  13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
   
• Lipectomy, liposuction, or any other excess fat-removal procedure
  
  15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879
   
• Otoplasty
  
  13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399
   
• Rhinoplasty
  
  30400, 30410, 30420, 30430, 30435, 30450
   
• Rhytidectomy
  
  15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876
   
• Scar revision
  
  13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
   
• Skin closures
  
  13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770
   
• Surgery for varicose veins, including perforators and sclerotherapy
  

​​​36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799

 

Elective (nonemergency) gr​​​ound, air, and sea ambulance transportation, including inpatient hospital-to-hospital transfers

A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961 

Outpatient private-duty nu​rsing

S9123, S9124 

Day rehabilitation progr​​ams

0931, 0932 

Outpatient radiation ​​therapy

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here. 

Radiology

Precertification is performed by AIM Specialty Health®. To access the complete list of AIM Specialty Health Diagnostic Imaging Utilization Management Clinical Guidelines, click here.  

• CT 
• CTA 
• Echocardiography services
  
• Testing transthoracic echocardiography (TTE) 
• Stress echocardiography (SE) 
• Transesophageal echocardiography (TE)
• MRA 
• MRI 
• Nuclear cardiology 
• ​PET scans 

Prosthetics/orthoses​​​ including: 

• Custom ankle-foot orthoses
  
  L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631​
   
• Custom knee-ankle-foot orthoses
  
  L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128
   
• Custom knee braces
  
  L1834, L1840, L1844, L1846, L1860
   
• ​Custom limb prost​hetics including accessories/components
  

L5010, L5020, L5050, L​​5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6050, L6055, L6100, L6110, L6120, L6130, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7260, L7400, L7401, L7402, L7403, L7404, L7405, L7499

 

Selected durable medi​​​​cal equipment (DME) 

• Bone growth stimulators
  
  E0747, E0760
   
• Bone growth stimulator, electrical, noninvasive, spinal
  
  Precertification is performed by AIM Specialty Health®. For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.
   
• Bone-anchored (osseointegrated) hearing aids
  
  L8690, L8691, L8692, L8693, L8694
   
• Continuous positive airway pressure (CPAP) devices, bi-level (Bi-PAP) devices, and all supplies
  
  Precertification is performed by AIM Specialty Health®. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click here.
   
• Dynamic adjustable and static progressive stretching devices (excludes CPMs)
  
  E1800, E1802, E1805, E1810, E1812, E1825, E1830
   
• Electric, power, and motorized wheelchairs including custom accessories
  
  E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294 E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2373, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613 E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630 K0010, K0011, K0012, K0013, K0014, K0056, K0108, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823 K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862 K0863, K0864, K0890, K0891, K0898
   
• Insulin pumps
  
  E0784, E0787, S1034
   
• Manual wheelchairs with the exception of those that are rented
  
  E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039 E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110  E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222  E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270  E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608  E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628  E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108
   
• Negative pressure wound therapy
  
  A6550, A9272, E2402, K0743, K0744, K0745, K0746
   
• Neuromuscular stimulators
  
  E0744, E0745, E0764, E0770
   
• Power operated vehicles (POV)
  
  E1230, K0800, K0801, K0802, K0812
   
• Pressure reducing support surfaces including: 

• Air fluidized bed
  
  E0194
   
• Non powered advanced pressure reducing mattress
  
  E0371, E0373
   
• Powered air flotation bed (low air loss therapy)
  
  E0193, E0372
   
• Powered pressure reducing mattress
  
  E0277 

• Push rim activated power assist devices
  
  E0986
   
• Repair or replacement of all DME items, as well as orthoses and prosthetics that require precertification
  
  E2368, E2369, E2370, E2374, E2375, E2376
   
• Speech gen​erating devices
  

E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336

 

Medica​​​​l foods​

B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435 

Hyperbaric oxygen therapy

0413, G0277 

Proton beam ther​​apy

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here. 

Sleep studies (facility based)

Precertification is performed by AIM Specialty Health®. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click here.
 

All transplant procedures, with the exception of corneal tra​nsplants

0584T, 0585T, 0586T, 15775, 15776, 27415, 27416, 29866, 29867, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150  

Mental health/serious mental illness/substa​​nce abuse

Precertification review for these services is provided by Magellan Healthcare, Inc.

 

• Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs) 
• Repetitive transcranial magnetic stimulation (RTMS) 
• ​Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs) 

Autism spectrum diso​​​rders 

• Applied behavioral analysis
  Precertifica​tion review for this service is provided by Magellan Healthcare, Inc. 

Genetic and genomic tests requiring ​​​precertification

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here. 

The following list is a guide to the types of genetic and genomic tests that require precertification. Due to the volume of tests, it is not possible to list each test separately. To determine if a test requires precertification, please see the complete procedure code list for details. Please note: precertification of genetic and genomic tests applies to commercial members only. 

Hereditary cancer syndrom​es 

• BRCA gene testing (breast and ovarian cancer syndrome) 
• Lynch syndrome gene testing 
• Familial adenomatous polyposis gene testing 
• PTEN gene testing (Cowden syndrome) 
• ​General cancer type panels (such as colon, breast, or neuroendocrine cancers) 

Hereditary heart dis​​eases 

• Long QT syndrome gene testing 
• ​Aortic dilation or a​neurysm syndrome testing (includes Marfan syndrome) 

Other full gene an​​alysis testing 

• Cystic fibrosis full gene sequencing and deletion/duplication analysis 
• ​PMP22 full gene sequencing and deletio​n/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy) 

Tests for many genetic disorders simultane​​ously 

• Expanded carrier screening panels (such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening) 
• Hearing loss panels 
• Intellectual disability panels 
• Noonan spectrum diso​rders panels 

Specialty onc​​​​ology tests

• Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™) 
• Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others) 
• Tissue of origin testing (for cancer of unknown primary) 
• ​PCA3 testing for prostate cancer 

Pharmacogenomic tes​​ts 

• Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19) 
• Specialized drug response gene panels (such as Assurex GeneSight®, GeneTrait, Genecept®, Millennium PGT^SM) 
• Warfarin response testing 
• ​MGMT methylati​on analysis for glioblastoma 

Other specialty​​​ tests 

• Coronary artery disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6) 
• ​Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR) 

Geno​​​me-wide tests 

• Microarray studies 
• Whole exome testing 
• Whole genome testing 
• ​Mitochondrial genome or nuclear testing 

ANY genetic test for more than one gene or c​​​ondition (often includes words like “panel" or “comprehensive" in the name) 

ANY genetic test that will be billed with a ​​non-specific procedure code 

• Billed with CPT® codes 81400-81408 
• Billed with an unlisted code: 81479, 81599, 84999 

Specialty drugs requiring pr​​ecertification

All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change. 

Antineoplastic ag​​ents 

• Abraxane® - J9264
• Adcetris® - J9042
• Alimta® - J9305
• Avastin® - C9257 and J9035 (Note: Opthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
• Azedra - A9590
• Azedra Dosimetric - A9590
• Blenrep - J3590 and C9069
• Blincyto™ - J9039
• Cyramza® - J9308
• Darzalex™ - J9145
• Darzalex Faspro – J9144
• Elzonris™ - J9269
• Enhertu® - J9358
• Erbitux® - J9055
• Erwinaze® - J9019
• Herceptin® - J9355 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
• Herceptin® Hylecta - J9356
• Herzuma - Q5113
• Instiladrin (pending FDA approval) - J3490 and C9399
• Kadcyla® - J9354
• Kanjinti™ - Q5117
• Kyprolis® - J9047
• Lumoxiti™ - J9313
• Margenza™ - J3490, J3590, and C9399
• Mvasi™ - Q5107 (Note: Opthalmologic use of Mvasi does not require precertification.)
• Ogivri - Q5114
• Ontruzant - Q5112
• Padcev- J9177
• Pemfexy - J9304
• Perjeta® - J9306
• Phesgo – J9316
• Polivy - J9309
• Poteligeo® - J9204
• Provenge® - Q2043
• Riabni™ - J3490, J3590, and C9399
• Rituxan® - J9312 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
• Rituxan Hycela™ - J9311
• Ruxience™ - Q5119
• Sarclisa® - J9227
• Taclantis™ (pending FDA approval) - J3490 and C9399
• Tecartus™ (pending FDA approval) – J3590 and C9073
• Trazimera™ - Q5116
• Trodelvy™ - J9317
• Truxima™ - Q5115
• Xofigo®* - A9606
• Yervoy™ - J9228
• Zepzelca – J9223
• Zevalin®* - A9543
• Zirabev™ - Q5118
• Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T         
  * Prec​ertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here. 

Anti PD-1/PD-L1 human monoclonal antibodies

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 

• Bavencio® - J9023
• Dostarlimab (pending FDA approval) – J3490, J3590, and C9399
• Imfinzi™ - J9173
• Keytruda™ - J9271
• Libtayo® - J9119
• Opdivo® - J9299
• ​​Tecentriq™ - J9022 

Bone-modifying a​​gents 

• Evenity™ - J3111
• Prolia® - J0897
• ​Xgeva® - J0897 

Botulinum toxin agent​​s 

• ​Botox® - J0585 

Chemotherapy-induced n​​​ausea and vomiting (CINV) agents

• ​Sustol® - J1627 

Chimeric antigen receptor (CAR-T) thera​​pies

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  

• Ciltacabtagene Autoleucel (pending FDA approval) – J3490, J3590, and C9399
• Idecabtagene Vicleucel (pending FDA approval) – J3490, J3590, and C9399
• Kymriah™ - Q2042
• Lisocabtagene maraleucel (pending FDA approval) - J3490, J3590, and C9399
• ​Yescarta™ - Q2041 

Colony stimulating​​ factors 

• Fulphila™ - Q5108
• Lapelga (pending FDA approval) - J3490, J3590, and C9399
• Neulasta® - J2505 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
• Neulasta Onpro™ - J2505
• Neupogen® - J1442
• Nivestym™ - Q5110
• Nyvepria™ – Q5122
• Rolontis® (pending FDA approval) - J3490 and C9399
• Udenyca™ - Q5111
• ​Ziextenzo® - Q5120

Duchenne muscular dystrophy​​​ agents

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 

• Casemirsen (pending FDA approval) - J3490, J3590, and C9399
• ​Viltolarsen (pending FDA approval) - J3490, J3590, and C9399 

Endocrine/m​​etabolic agents 

• Cosyntropin depot (pending FDA approval) - J3490, J3590, and C9399
• H.P. Acthar® - J0800
• Lutathera®* - A9513 and A9699
• Makena® - J1726 and J1729
• Sandostatin® LAR - J2353
• Somatuline® depot - J1930 
  * Precertification review​ is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here.

Enzyme replacement agen​​​ts

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  

• Aldurazyme® - J1931
• Brineura™ - J0567
• Cerezyme® - J1786
• Elaprase® - J1743
• Elelyso® - J3060
• Fabrazyme® - J0180
• Kanuma® - J2840
• Lumizyme® - J0221
• Mepsevii™ - J3397
• Naglazyme® - J1458
• Pegunigalsidase Alfa (pending FDA approval) – J3490, J3590, and C9399
• Replagal® (pending FDA approval) - J3490  
• Revcovi™ - J3590 and C9399
• Vimizim™ - J1322
• ​VPRIV® - J3385 

Gen​e therapy

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

• Luxturna™ - J3398
• Valrox (pending FDA approval) - J3490 and C9399
• Zolgensma® - J3399
• ​Zynte​glo (pending FDA approval) - J3490, J3590, and C9399 

Hemophilia/Coagulation fac​​tors

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  

• Advate - J7192
• Adynovate - J7207
• Afstyla - J7210
• Alphanate - J7186
• Alphanine SD - J7193
• Alprolix - J7201
• Autoplex T - J7198
• Bebulin VH - J7194
• Bebulin - J7194
• Benefix - J7195
• Bioclate - J7192
• Coagadex - J7175
• Corifact - J7180
• Eloctate - J7205
• Esperoct- J7204
• Feiba NF - J7198
• Feiba VH - J7198
• Fibryga - J7177
• Fibryna - J7178
• Helixate FS - J7192
• Hemlibra - J7170
• Hemofil-M - J7190
• Humate-P - J7187
• Hyate-C - J7191
• Idelvion - J7202
• Ixinity - J7199
• Jivi® - J7199 and J7208
• Koate-DV I- J7190
• Kogenate FS - J7192
• Kovaltry - J7207 and J7211
• Monarc - J7190
• Monoclate-P - J7190
• Mononine - J7193
• Novoeight - J7182
• Novoseven RT - J7189
• Novoseven - J7189
• Nuwiq - J7209
• Obizur - J7188
• Profilnine SD - J7194
• Proplex T - J7194
• Rebinyn - J7203
• Recombinate - J7192
• Refacto - J7192
• RiaSTAP - J7178
• Rixubis - J7195 and J7200
• Sevenfact – J7212
• Tretten - J7181
• Vonvendi - J7179 and J7199
• Wilate - J7183
• ​Xyntha - J7185 

Hyaluronate acid​​​ products 

• Cingal (pending FDA approval) - J3490
• Durolane® - J7318
• Euflexxa™ - J7323
• Gel-One® - J7326
• Gelsyn-3™ - J7328
• GenVisc 850® - J7320
• Hyalgan® - J7321
• Hymovis® - J7322
• Supartz® - J7321
• Synojoynt - J7331
• Triluron - J7332
• TriVisc™ - J7329
• ​VISCO-3® - J7333 

Immunologica​​l agents 

• Actemra® - J3262
• Avsola™ - Q5121
• Benlysta® - J0490
• Entyvio™ - J3380
• Ilumya™ - J3245
• Inflectra™ - Q5103
• Ixifi™ - Q5109
• Orencia® - J0129
• Remicade® - J1745 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
• Renflexis™ - Q5104
• Simponi® Aria - J1602
• Stelara® - J3357 and J3358  

Intravenous Immune Globulin/Su​​bcutaneous Immune Globulin (IVIG/SCIG)

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
 

• Intravenous Immune Globulin (IVIG) 

• Asceniv - J1599 and C9072
• Bivigam - J1556
• Carimune - J1566
• Flebogamma - J1572
• Flebogamma-Dif - J1572
• Gammagard - J1569
• Gammagard Liquid - J1569
• Gammagard S/D - J1566
• Gammaked - J1561
• Gammaplex - J1557
• Gamunex-C - J1561
• Octagam - J1568
• Panzyga - J1599
• Privigen - J1459 

• Subcutaneous Immune Globulin (SCIG)
  

• Cutaquig - J7799
• Cuvitru - J1555
• Hizentra - J1559
• Hyqvia - J1575
• ​​Xe​​​mbify - J1558 

Multiple​ scleros​is ​agents

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

• Lemtrada® - J0202
• Ocrevus™ - J2350
• ​Ty​sabri® - J2323 

Ophthalmi​​​c agents 

• Abicipar (pending FDA approval) - J3490, J3590, and C9399
• Beovu® - J0179
• Eylea® - J0178
• Lucentis® - J2778
• Macugen® - J2503
• Ranibizumab Biosimilar (pending FDA approval) – J3490, J3590, and C9399
• ​Tepezza® - J3241

Pulmonary arterial hyperten​​​sion

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 

• Flolan® - J1325
• Remodulin® - J3285
• Revatio® - J3490 and C9399
• Trevyent (pending FDA approval) - J3490 and C9399
• Tyvaso® - J7686
• Veletri® - J1325
• Ventavis® - Q4074 

Respiratory ag​​​ents 

• Cinqair® - J2786
• Synagis® - 90378
• ​Xolair® - J2357 

Respiratory enzyme​​s (Alpha-1 antitrypsin)

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  

• Aralast - J0256
• Glassia™ - J0257
• Prolastin® - J0256
• ​Zemaira® - J0256 

Miscellaneous therapeuti​​​c agents 

• Adakveo® - J0791
• Ampligen® (pending FDA approval) - J3490
• Crysvita - J0584
• Evianacumab (pending FDA approval) – J3490, J3590, and C9399
• Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
• Gamifant® - J9210
• Givlaari - J0223
• Ilaris - J0638
• Inclisiran (pending FDA approval) – J3490, J3590, and C9399
• Inebilizumab (pending FDA approval)- J3490 and C9399
• Krystexxa - J2507
• Onpattro® - J0222
• Oxlumo™ – J3490, J3590, and C9399
• Radicava - J1301
• Reblozyl® - J0896
• Remune (pending FDA approval) - J3490
• Rethymic™ (RVT-802) (pending FDA approval) - J3490, J3590, and C9399
• Soliris® - J1300 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
• Spinraza - J2326
• Trogarzo - J1746
• Ultomiris™ - J1303
• Uplizna – J1823
• Vyepti™ - J3032
• Xiaflex® – J0775 

Revisio​​​ns

​ 

​​   January 1, 2021 The following revisions were incorporated into the January 1, 2021 update. Additions, drugs added Antineoplastic agents Margenza™ - J3490, J3590, and C9399 Riabni™ - J3490, J3590, and C9399 Tecartus™ (pending FDA approval) – J3590 and C9073 Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T  Anti PD-1/PD-L1 human monoclonal antibodies ​Dostarlimab (pending FDA approval) – J3490, J3590, and C9399  Chimeric antigen receptor (​​CAR-T) therapies Ciltacabtagene Autoleucel (pending FDA approval) – J3490, J3590, and C9399 ​Idecabtagene Vicleucel (pending FDA approval) – J3490, J3590, and C9399 Colony stimulating factor​​​​s Neupogen® - J1442 ​Nyvepria™ – Q5122  Enzyme replacement agents ​Pegunigalsidase Alfa (pending FDA approval) – J3490, J3590, and C9399 Ophthalmic ag​​ents ​Ranibizumab Biosimilar (pending FDA approval) – J3490, J3590, and C9399  Miscellaneous therapeutic a​​​gents Evianacumab (pending FDA approval) – J3490, J3590, and C9399 Inclisiran (pending FDA approval) – J3490, J3590, and C9399 Oxlumo™ – J3490, J3590, and C9399 ​Xia​flex® – J0775  Additions, codes added​  Antineoplastic agents Blenrep – C9069 Darzalex Faspro – J9144 Phesgo – J9316 Trodelvy™ - J9317 ​Zepzelca™ - J9223 Hemophilia/Coagulation factors​​ Sevenfact – J7212  Intravenous Immune Globulin/Subc​​utaneous Immune Globulin (IVIG/SCIG) ​Asceniv – C9072 Miscellaneous the​​rapeutic agents ​Uplizna – J1823 Additions, language added​    Antineoplastic agents Instiladrin – (pending FDA approval) ​Taclantis™ – (pending FDA approval) Colony stimulating f​​​​actors ​Rolontis® – (pending FDA approval)  Duchenne muscular dystroph​​y agents All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  Gene therapy ​Valrox – (pending FDA approval) Pulmonary arterial hyperten​​sion All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  ​Trevyent – (pending FDA approval)  Miscellaneous ther​​​apeutic agents ​Inebilizumab – (pending FDA approval) Deletions, drugs removed​  Antineoplastic ag​ents Halaven® – J9719 Jevtana® – J9043 ​Margetuximab (pending FDA approval) - J3490, J3590, and C9399 Duchenne muscular dystrophy agents Exondys-51™ – J1428 ​Vyondys 53 – J1429 Respiratory agen​​​ts Fasenra™ – J0517 ​Nucala® – J2182  Miscellaneou​s therapeutic agents Ravulizumab – J3490 ​Sylvant​™ – J2860  Deletions, codes removed​  Reconstructive procedures and potentially cosmetic procedures Breast Reconstruction – 19366 ​Breast Augmentation/Mammoplasty – 19324  Antineoplastic agents Blenrep – C9399 Darzalex Faspro – C9062 Phesgo – J3590 and C9399 Trodelvy™ – J3590 and C9066 ​Zepzelca™ – J3490 and C9399 Hemophilia/Co​​agulation factors ​Sevenfact – J7189  Miscellaneou​​s therapeutic agents ​Uplizna – J3490 and C9399  Deletions, language removed​  Ophthalmic agents All drugs that can be cl​assified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

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