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:
| HCPCS Code | Medical Injection Drugs that require prior authorization (brand name examples included for reference only) |
Subject to Site-of-Service prior authorization? YES (Y) or NO (N) |
Effective Date |
|---|---|---|---|
| J3262 | Actemra IV | Y | 1/1/2019 |
| J9035 | Avastin | N | 1/1/2019 |
| J0490 | Benlysta IV | Y | 1/1/2019 |
| J1556 | Bivigam | Y | 1/1/2019 |
| J0585 | Botox | Y | 1/1/2019 |
| J1566 | Carimune, Gammagard S/D, Panglobulin NF | Y | 1/1/2019 |
| J0717 | Cimzia lyophilized powder | Y | 1/1/2019 |
| J0586 | Dysport | Y | 1/1/2019 |
| J3380 | Entyvio | Y | 1/1/2019 |
| J7323 | Euflexxa | Y | 1/1/2019 |
| J0178 | Eylea | N | 1/1/2019 |
| J1572 | Flebogamma | Y | 1/1/2019 |
| Q5108 | Fulphila | N | 1/1/2019 |
| J1569 | Gammagard liquid | Y | 1/1/2019 |
| J1557 | Gammaplex | Y | 1/1/2019 |
| J1561 | Gammunex-c, Gammaked | Y | 1/1/2019 |
| J7326 | Gel-one | Y | 1/1/2019 |
| J7328 | Gelsyn 3 | Y | 1/1/2019 |
| J7320 | Genvisc 850 | Y | 1/1/2019 |
| J9355 | Herceptin | N | 1/1/2019 |
| J1559 | Hizentra | Y | 1/1/2019 |
| J7321 | Hyalgan, Supartz | Y | 1/1/2019 |
| J7322 | Hymovis | Y | 1/1/2019 |
| J1575 | Hyqvia | Y | 1/1/2019 |
| Q5103 | Inflectra | Y | 1/1/2019 |
| Q2042 | Kymriah | N | 1/1/2019 |
| J0202 | Lemtrada | Y | 1/1/2019 |
| J2778 | Lucentis | N | 1/1/2019 |
| J7327 | Monovisc | Y | 1/1/2019 |
| J0587 | Myobloc | Y | 1/1/2019 |
| J2505 | Neulasta | N | 1/1/2019 |
| J2182 | Nucala | N | 1/1/2019 |
| J2350 | Ocrevus | Y | 1/1/2019 |
| J1568 | Octagam | Y | 1/1/2019 |
| J9299 | Opdivo | N | 1/1/2019 |
| J0129 | Orencia IV | Y | 1/1/2019 |
| J7324 | Orthovisc | Y | 1/1/2019 |
| J1459 | Privigen | Y | 1/1/2019 |
| J0897 | Prolia, Xgeva | Y | 1/1/2019 |
| J1745 | Remicade | Y | 1/1/2019 |
| Q5104 | Renflexis | Y | 1/1/2019 |
| J9312 | Rituxan | Y | 1/1/2019 |
| J1602 | Simponi Aria | Y | 1/1/2019 |
| 90378 | Synagis | Y | 1/1/2019 |
| J7325 | Synvisc | Y | 1/1/2019 |
| J2323 | Tysabri | Y | 1/1/2019 |
| J0588 | Xeomin | Y | 1/1/2019 |
| J2357 | Xolair | N | 1/1/2019 |
| Q2041 | Yescarta | N | 1/1/2019 |
| J9305 | Alimta | N | 4/1/2019 |
| J7318 | Durolane | Y | 4/1/2019 |
| J0517 | Fasenra | N | 4/1/2019 |
| J3245 | Ilumya | Y | 4/1/2019 |
| Q5109 | Ixifi | Y | 4/1/2019 |
| J3398 | Luxturna | N | 4/1/2019 |
| J9311 | Rituxan Hycela | Y | 4/1/2019 |
| J1628 | Tremfya | Y | 4/1/2019 |
| J7329 | Trivisc | Y | 4/1/2019 |
| Q5111 | Udenyca | N | 4/1/2019 |
| J1555 | Cuvitru | Y | 7/1/2019 |
| Q5107 | Mvasi | N | 7/1/2019 |
| J1599 | Panzyga, Asceniv | Y | 7/1/2019 |
| J3358 | Stelara IV | Y | 7/1/2019 |
| J9217 | Eligard, Lupron Depot | N | 10/1/2019 |
| J0800 | H.P. Acthar Gel | N | 10/1/2019 |
| J9356 | Herceptin Hylecta | N | 10/1/2019 |
| J9218 | Leuprolide Acetate | N | 10/1/2019 |
| J1950 | Lupron Depot, Fensolvi | N | 10/1/2019 |
| J2796 | Nplate | N | 10/1/2019 |
| J9226 | Supprelin LA | N | 10/1/2019 |
| J3316 | Triptodur | N | 10/1/2019 |
| J3031 | Ajovy | N | 1/1/2020 |
| J3111 | Evenity | Y | 1/1/2020 |
| Q5113 | Herzuma | N | 1/1/2020 |
| Q5117 | Kanjinti | N | 1/1/2020 |
| Q5114 | Ogivri | N | 1/1/2020 |
| Q5112 | Ontruzant | N | 1/1/2020 |
| J7331 | SynoJoynt | Y | 1/1/2020 |
| Q5116 | Trazimera | N | 1/1/2020 |
| J7332 | Triluron | Y | 1/1/2020 |
| Q5115 | Truxima | Y | 1/1/2020 |
| Q5118 | Zirabev | N | 1/1/2020 |
| J0179 | Beovu | N | 4/1/2020 |
| J9309 | Polivy | N | 4/1/2020 |
| J0791 | Adakveo | N | 8/1/2020 |
| J7333 | Visco-3 | Y | 8/1/2020 |
| J1429 | Vyondys 53 | N | 8/1/2020 |
| J0598 | Cinryze | N | 1/1/2021 |
| J2326 | Spinraza | N | 1/1/2021 |
| J3399 | Zolgensma | N | 1/1/2021 |
| J9216 | Actimmune | N | 3/1/2021 |
| J7189 | Novoseven | N | 3/1/2021 |
| Q5122 | Nyvepria | N | 3/1/2021 |
| J3590 | Revcovi | N | 3/1/2021 |
| J1300 | Soliris | N | 3/1/2021 |
| J1303 | Ultomiris | N | 3/1/2021 |
| J1322 | Vimizim | N | 3/1/2021 |
| J1554 | Asceniv | Y | 4/1/2021 |
| Q5121 | Avsola | Y | 4/1/2021 |
| J0223 | Givlaari | N | 4/1/2021 |
| Q5119 | Ruxience | Y | 4/1/2021 |
| J3032 | Vyepti | Y | 4/1/2021 |
| J1558 | Xembify | Y | 4/1/2021 |
| Q5120 | Ziextenzo | N | 4/1/2021 |
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.
| Effective Date of Biosimilar Preference | Non-Preferred Medical Injection Drug | Preferred Biosimilar |
|---|---|---|
| 10/1/2019 | Remicade ( J1745) | Renflexis ( Q5104), Inflectra (Q5103), Ixifi (Q5109), & Avsola (Q5121) |
| 10/1/2019 | Neulasta (J2505) | Fulphila (Q5108), Udenyca (Q5111) & Ziextenzo (Q5120), Nyvepria (Q5122) |
| 1/1/2020 | 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) |
To request prior authorization, submit the Medical Injectable Prior Authorization form along with clinical supporting documentation via fax to 410-424-2801.