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Specialty Medications - Medical Benefit

Effective January 1, 2019, Johns Hopkins HealthCare LLC (JHHC) requires prior authorization to determine medical necessity for certain provider-administered medications (procedure codes are listed in the chart below). These new requirements impact Priority Partners members of all ages.

The following HCPCS Codes require medical necessity prior authorization.  Some drugs are also subject to site-of-service (site-of-care) prior authorization:

*NOTE: These codes require medical necessity authorization only (not site of service).

Medical Injection-Brand NameHPCS CodeEffective Date
Actemra IVJ32621/1/2019
AvastinJ9035*1/1/2019
Benlysta IVJ04901/1/2019
BivigamJ15561/1/2019
BotoxJ05851/1/2019
Carimune, Gammagard S/D, Panglobulin NF J15661/1/2019
Cimzia lyophilized powderJ07171/1/2019
DysportJ05861/1/2019
EntyvioJ33801/1/2019
EuflexxaJ73231/1/2019
EyleaJ0178*1/1/2019
FlebogammaJ15721/1/2019
FulphilaQ5108*1/1/2019
Gammagard liquidJ15691/1/2019
GammaplexJ15571/1/2019
Gammunex-c, GammakedJ15611/1/2019
Gel-oneJ73261/1/2019
Gelsyn 3J73281/1/2019
Genvisc 850J73201/1/2019
HerceptinJ9355*1/1/2019
HizentraJ15591/1/2019
Hyalgan, SupartzJ73211/1/2019
HymovisJ73221/1/2019
HyqviaJ15751/1/2019
InflectraQ51031/1/2019
KymriahQ2042*1/1/2019
LemtradaJ02021/1/2019
LucentisJ2778*1/1/2019
MonoviscJ73271/1/2019
MyoblocJ05871/1/2019
NeulastaJ2505*1/1/2019
NucalaJ2182*1/1/2019
OcrevusJ23501/1/2019
OctagamJ15681/1/2019
OpdivoJ9299*1/1/2019
Orencia IVJ01291/1/2019
OrthoviscJ73241/1/2019
PrivigenJ14591/1/2019
Prolia, XgevaJ08971/1/2019
RemicadeJ17451/1/2019
RenflexisQ51041/1/2019
RituxanJ93121/1/2019
Simponi ariaJ16021/1/2019
Synagis903781/1/2019
SynviscJ73251/1/2019
TysabriJ23231/1/2019
XeominJ05881/1/2019
XolairJ2357*1/1/2019
YescartaQ2041*1/1/2019
AlimtaJ9305*4/1/2019
DurolaneJ73184/1/2019
FasenraJ0517*4/1/2019
IlumyaJ32454/1/2019
IxifiQ51094/1/2019
LuxturnaJ3398*4/1/2019
Rituxan HycelaJ93114/1/2019
TremfyaJ16284/1/2019
TriviscJ73294/1/2019
UdenycaQ5111*4/1/2019
MvasiQ5107*7/1/2019
CuvitruJ15557/1/2019
PanzygaJ15997/1/2019
Stelara IVJ33587/1/2019
H.P. Acthar GelJ0800*10/1/2019
Lupron Depot J1950*10/1/2019
Leuprolide AcetateJ9218*10/1/2019
Eligard, Lupron DepotJ9217*10/1/2019
NplateJ2796*10/1/2019
Supprelin LAJ9226*10/1/2019
TriptodurJ3316*10/1/2019
Herceptin Hylecta J9356*10/1/2019
EvenityJ31111/1/2020
AjovyJ3031*1/1/2020
KanjintiQ5117*1/1/2020
OntruzantQ5112*1/1/2020
HerzumaQ5113*1/1/2020
OgivriQ5114*1/1/2020
TrazimeraQ5116*1/1/2020
TruximaQ51151/1/2020
ZirabevQ5118*1/1/2020
SynoJoyntJ73311/1/2020
TriluronJ73321/1/2020
BeovuJ0179*4/1/2020
PolivyJ93094/1/2020
AdakveoJ0791*8/1/2020
Vyondys 53J1429*8/1/2020
Visco-3J73338/1/2020
GivlaariJ0223*10/1/2020
RuxienceQ511910/1/2020
ZiextenzoQ5120*10/1/2020
AvsolaQ512110/1/2020
XembifyJ155810/1/2020
VyeptiC906310/1/2020

* Not subject to Site of Care Requirement

To request prior authorization, submit the Medical Injectable Prior Authorization form along with clinical supporting documentation via fax to 410-424-2801.

Biosimilar Drugs

The following is a list of preferred biosimilar drugs.  Use of preferred biosimilar product prior to the use of non-preferred product is required. Please note the preferred biosimilar are subject to prior authorization. 

Non-Preferred Medical Injection DrugPreferred BiosimilarEffective Date
Remicade ( J1745)Renflexis ( Q5104)10/1/2019
Neulasta (J2505)Fulphila (Q5108), Udenyca (Q5111) & Ziextenzo (Q5120)10/1/2019
Rituxan (J9312)Truxima (Q5115) & Ruxience (Q5119) (preference is applicable for select indications)1/1/2020
Avastin (J9035)Mvasi (Q5107) & Zirabev (Q5118) (preference is applicable for select indications)1/1/2020
Herceptin (J9355)Kanjinti (Q5117), Ontruzant (Q5112), Herzuma (Q5113), Ogivri (Q5114), & Trazimera (Q5116)1/1/2020