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.