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PRIOR AUTHORIZATION – MEDICINES AND INJECTIBLES
The following list of drugs requires authorization under the Medicare Part B Benefit:
HCPCS
Code
Short Description
HCPCS
Code
Short Description
HCPCS
Code
Short Description
HCPCS
Code
Short Description
J0129 Abatacept, inj J0735 Clonidine
hydrochloride
Q2009 Fosphenytoin, 50 mg J9230 Mechlorethamine hcl
inj
J0130 Abciximab injection J0770 Colistimethate
sodium inj
J1458 Galsulfase, inj J7669 Metaproterenol non-
comp unit dose
J7608 Acetylcysteine inh sol u J0800 Corticotropin
injection
J1560 Gamma globulin >
10 CC inj
J7674 Methacholine
chloride, neb
J0132 Acetylcysteine injection J7631 Cromolyn sodium inh
sol u d
J1460 Gamma globulin 1
CC inj
J7505 Monoclonal
antibodies
J0135 Adalimumab injection J7330 Cultured
chondrocytes implnt
J1550 Gamma globulin 10
CC inj
Q4079 Natalizumab
injection
J0180 Agalsidase beta injection J9100 Cytarabine hcl 100
MG inj
J1470 Gamma globulin 2
CC inj
J9261 Nelarabine injection
Q4093 Albuterol inh non-comp
con (Initial auth only)
J9110 Cytarabine hcl 500
MG inj
J1480 Gamma globulin 3
CC inj
Q4087 Octagam Injection
Q4094 Albuterol inh non-comp
u d (Initial auth only)
J9098 Cytarabine liposome J1490 Gamma globulin 4
CC inj
J2357 Omalizumab
injection
J7620 Albuterol ipratrop non-
comp
J0850 Cytomegalovirus
imm IV /vial
J1500 Gamma globulin 5
CC inj
J2355 Oprelvekin injection
J9015 Aldesleukin/single use
vial
J9130 Dacarbazine 100 mg
inj
J1510 Gamma globulin 6
CC inj
Q4086 Orthovisc, inj
J0215 Alefacept J9140 Dacarbazine 200 MG
inj
J1520 Gamma globulin 7
CC inj
J9263 Oxaliplatin
J9010 Alemtuzumab injection J7513 Daclizumab,
parenteral
J1530 Gamma globulin 8
CC inj
J9265 Paclitaxel injection
J0205 Alglucerase injection J9120 Dactinomycin
actinomycin d
J1540 Gamma globulin 9
CC inj
J9264 Paclitaxel protein
bound
J0256 Alpha 1 proteinase
inhibitor
J1645 Dalteparin sodium Q4088 Gammagard Liquid
injection
J2425 Palifermin injection
J0270 Alprostadil for injection J0882 Darbepoetin alfa,
esrd use
Q4092 Gamunex injection J2469 Palonosetron HCl
J0275 Alprostadil urethral
suppos
J0881 Darbepoetin alfa,
non-esrd
J7310 Ganciclovir long act
implant
J2430 Pamidronate
disodium /30 MG
J2997 Alteplase recombinant J9150 Daunorubicin J9201 Gemcitabine HCl J2504 Pegademase bovine,
25 iu
J0207 Amifostine J9151 Daunorubicin citrate
liposom
J9300 Gemtuzumab
ozogamicin
J2503 Pegaptanib sodium
injection
J0288 Ampho b cholesteryl
sulfate
J0894 Decitabine, inj J9202 Goserelin acetate
implant
J9266 Pegaspargase/singl
dose vial
J0285 Amphotericin B J0895 Deferoxamine
mesylate inj
Q4090 HepaGam B IM
Injection
J9305 Pemetrexed injection
J0287 Amphotericin b lipid
complex
J9160 Denileukin diftitox,
300 mcg
J9225 Histrelin implant J9268 Pentostatin injection
J0289 Amphotericin b liposome
inj
J1190 Dexrazoxane HCl
injection
Q4083 Hyalgan or Supartz,
inj
J9600 Porfimer sodium
J0348 Anadulafungin injection J1162 Digoxin immune fab
(ovine)
J3470 Hyaluronidase
injection
J2783 Rasburicase
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