Download pdf - Specialty Medication List - AZBlue/media/azblue/files/pharmacy... · 2020-04-22 · Specialty Drug eviCore for delegated members; BCBSAZ for all other members 90283 Immune Globulin

D24764 04/2020 Page 1 of 21 Medical Benefit - Specialty Medication List

Medical BenefitSpecialty Medication ListRevised 4/1/2020

This list pertains to specialty medications that need to be administered by a healthcare professional and are covered under the medical benefit , such as intravenous and other injectables. This list is subject to change at any time without notice.

For specialty medications that are covered under the pharmacy benefit, click here.

This list includes specific codes that require prior authorization for most Blue Cross® Blue Shield® of Arizona (BCBSAZ) plans.

This list does not does not apply to the following plans: Federal Employee Program® (FEP®) plans Medicare Advantage (MA) plans Employer-sponsored plans in our Corporate Health Services (CHS) program Plans offered or administered by other Blue Cross and/or Blue Shield plans Certain employer-sponsored health plans with customized benefits and prior authorization requirements ADOA State of Arizona (group 030855) City of Phoenix (groups 040000 and 040004) Northwest Arizona Employee Benefit Trust (group 037461) Snell & Wilner (group 030313) OB Sports Golf Management, LLC (group 038043) Teamsters (groups 031843 and 031844)

For benefits and eligibility, or to inquire about prior authorization requirements for specialty medications not listed here or for one of the exempt plans listed above, you can call BCBSAZ at 602-864-4320 or 1-800-232-2345, ext 4320.

Filling specialty medications covered under the medical benefit • If the medication is on this list and requires prior authorization, you should submit a request. • Some of our network specialty pharmacy providers for these medications are: AllianceRx Walgreens Prime: 1-866-202-4014 Accredo Health Group, Inc.: 1-866-759-1557 Caremark LLC: 1-800-237-2767

Requesting prior authorization eviCore delegated members* For members who are delegated for the eviCore program, eviCore handles the prior authorization requests. You can use the secure online request tool at:evicore.com/provider#login

*How to determine if a BCBSAZ member is delegated for the eviCore commercial programYou can submit a 270/271 electronic transaction or use our eligibility and benefits search tool in the secure provider portal at azblue.com/providers. Select service type 30: “Health Benefit Plan Coverage.”

All other BCBSAZ membersFor members who are not delegated for the eviCore program, BCBSAZ handles the prior authorization requests. You can do either of the following:• Use the online request tool in the secure provider portal at azblue.com/providers > Practice Management > Precertification > BCBSAZ Members-Requests for 2020. In the tool, be sure to select "Medical" for your request. • Fax a prior authorization request to BCBSAZ Clinical Therapeutics Department at 602-864-5810.

Important: Chart notes must be included with your request.

http://www.evicore.com/provider#login�


Code Code Description Code Category Prior Authorization Administrator:BCBSAZ or eviCore

90281 Immune Globulin (Ig), human, for intramuscular use (Code Price is per 2 mL) (GAMASTAN, GAMASTAN S/D) - see also codes J1460 and J1560

Specialty Drug eviCore for delegated members; BCBSAZ for all other members

90283 Immune Globulin (IgIV), human, for intravenous use (Code Price is per 500 mg) (Use 90283 for CPT billing requirements ONLY - see also J1459, J1557, J1561, J1566, J1568, J1569, J1572 and J1599 for non-CPT billing)


90284 Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each (Use 90284 for CPT billing requirements ONLY - see also J1559, J1561, J1562, and J1569 for non-CPT billing)


90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each (SYNAGIS) palivizumab


C9015 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), HAEGARDA, 10 UNITS

Specialty Drug See Pharmacy Benefit tab.

C9036 injection, Onpattro (patisiran) 0.1 mg. Code deleted effective 9/30/2019. See J0222 (effective 10/1/2019).


C9038 Injection, mogamulizumab-kpkc, 1 mg (Code deleted effective 9/30/19) POTELIGEO) - See J9204

Medical Oncology - CHEMO

PA required only for eviCore delegated members

C9043 Levoleucovorin Medical Oncology - CHEMO


C9044 Libtayo (cemiplimab-rwlc, 1 mg) Code deleted effectie 9/30/2019. See J9119 for Libtayo effective 10/1/2019.


eviCore for delegated members; BCBSAZ for all other members

C9045 Lumoxiti (moxetumomab pasudotox-tdfk). Code deleted effective 9/30/19. See J9313 for Lumoxiti effective 10/1/2019.

Specialty Drug Medical Oncology -

CHEMO


C9047 Injection, caplacizumab-yhdp, 1 mg (CABLIVI) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

C9049 tagraxofusp-erzs, 10 mcg (ELZONRIS) (Code deleted effective 9/30/19)


CHEMO


C9052 Ultomiris (ravulizumab-cwvz) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

C9257 Injection, bevacizumab, 0.25 mg (AVASTIN) Specialty Drug PA required only for eviCore delegated members

C9399 dinutuximab (UNITUXIN) 3.5MG/ML Solution C9399. Unclassified drugs or biologicals



C9399 defibrotide (DEFITELIO) 80MG/ML Solution C9399 Unclassified drugs or biologicals


C9399 elapegademase-ivlr (REVCOVI) 2.4MG/1.5ML Solution C9399 Unclassified drugs or biologicals


C9399 pasireotide (SIGNIFOR) 0.3MG/ML Solution C9399 Unclassified drugs or biologicals


C9399 pegvaliase-pqpz (PALYNZIQ) 2.5MG/0.5ML Solution Prefilled Syringe C9399 Unclassified drugs or biologicals


C9399 ZOLGENSMA (onasemmogene abeparvovec-xioi) Kit C9399 Unclassified drugs or biologicals (This code should only be used for drugs and biologicals that are approved by the FDA on or after January 1, 2004) (Hospital Outpatient Use ONLY)


C9399 Unclassified drugs or biologicals (This code should only be used for drugs and biologicals that are approved by the FDA on or after January 1, 2004) (Hospital Outpatient Use ONLY)


CHEMO


C9466 injection, benralizumab, 1 mg (Fasenra) (Code deleted effective 12/31/2018)




J0129 INJECTION ABATACEPT 10 MG (Orencia) Specialty Drug BCBSAZ for all members and eviCore delegated members

J0135 Injection, adalimumab, 20 mg (Effective 6/1/18 use NDC level pricing for appropriate reimbursement based on NDC submitted) (HUMIRA)


J0178 Injection, aflibercept, 1 mg (EYLEA) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0180 INJ AGALSIDASE BETA 1 MG (Fabrazyme) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0185 Injection, aprepitant, 1 mg (Cinvanti) Medical Oncology - SPORT


J0202 Injection, alemtuzumab, 1 mg (Lemtrada) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0222 Injection, Patisiran, 0.1 mg (Onpattro) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0256 Injection, alpha 1-proteinase inhibitor, human, 10 mg, not otherwise specified (Aralast, Prolastin C, Zemaira)


J0257 Injection, alpha 1 proteinase inhibitor (human), (Glassia), 10 mg


J0364 Injection, apomorphine hydrochloride, 1 mg (Apokyn) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0490 Injection, belimumab, 10 mg (Benlysta) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0517 injection, benralizumab, 1 mg (Fasenra) (Code effective 1/1/2019)


J0565 Injection, bezlotoxumab, 10 mg (Zinplava) Specialty Drug PA required only for eviCore delegated members

J0584 Injection, burosumab-twza 1 mg (Crysvita) Specialty Drug PA required only for eviCore delegated members

J0585 Injection, onabotulinumtoxinA, 1 unit (Botox) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0586 Injection, abobotulinumtoxinA, 5 units (Dysport) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0587 Injection, rimabotulinumtoxinB, 100 units (Myobloc) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0588 Injection, incobotulinumtoxinA, 1 unit (Xeomin) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0596 Injection, c-1 esterase inhibitor (recombinant), Ruconest, 10 units


J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units


J0598 Injection, C1 esterase inhibitor (human), Cinryze, 10 units


J0606 Injection, etelcalcetide, 0.1 mg (Parsabiv) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0638 Injection, canakinumab, 1 mg (Ilaris) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J0640 Injection, leucovorin calcium, per 50 mg (Leucovorin Calcium)



J0641 Injection, levoleucovorin, not otherwise specified, 0.5 mg (Leucovorin Calcium)


CHEMO


J0717 Injection, certolizumab pegol, 1 mg (CIMZIA) Specialty Drug See Pharmacy Benefit tab.J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg

(Xiaflex)Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ0800 Injection, corticotropin, up to 40 units (ACTHAR) Specialty Drug See Pharmacy Benefit tab.J0881 Injection, darbepoetin alfa, 1 microgram (non-ESRD use)

(Aranesp)Specialty Drug

Medical Oncology - SPORT




J0882 Injection, darbepoetin alfa, 1 microgram (for ESRD on dialysis) (Aranesp)

Specialty Drug PA required only for all other BCBSAZ members

J0885 Injection, epoetin alfa, (for non-ESRD use), 1000 units (Procrit, Epogen)


SPORT


J0887 Injection, epoetin beta, 1 microgram, (for ESRD on dialysis) (Mircera)


J0888 Injection, epoetin beta, 1 microgram, (for non-ESRD use) (Mircera)


J0894 Injection, decitabine, 1 mg (DECITABINE, DAGOGEN) Medical Oncology - CHEMO


J0897 Injection, denosumab, 1 mg (Prolia) Specialty Drug Medical Oncology -

SPORT


J1290 Injection, ecallantide, 1 mg (KALBITOR) Specialty Drug See Pharmacy Benefit tab.J1300 Injection, eculizumab, 10 mg (Soliris) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ1301 Injection, edaravone, 1 mg (RADICAVA) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ1303 Injection, ravulizumab-cwvz, 10 mg (ULTOMIRIS) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ1322 Injection, elosulfase alfa, 1 mg (Vimizim) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ1324 Injection, enfuvirtide, 1 mg (FUZEON) Specialty Drug See Pharmacy Benefit tab.J1325 Injection, epoprostenol, 0.5 mg (see J3490 or S0155 for

billing epoprostenol diluent) (VELETRI, EPOPROSTENOL SODIUM, FLOLAN)


J1428 Injection, eteplirsen, 10 mg (EXONDYS 51) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J1438 Injection, etanercept, 25 mg (ENBREL) Specialty Drug See Pharmacy Benefit tab.J1439 Injection, ferric carboxymaltose, 1 mg (INJECTAFER) Specialty Drug PA required only for eviCore delegated

membersJ1442 Injection, filgrastim (G-CSF), excludes biosimilars, 1

microgram (NEUPOGEN)Specialty Drug



J1447 Injection, tbo-filgrastim, 1 microgram (GRANIX) Medical Oncology - SPORT


J1453 Injection, fosaprepitant, 1 mg (EMEND, FOSAPREPITANT DIMEGLUMINE)



J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg (AKYNZEO)



J1458 Injection, galsulfase, 1 mg (NAGLAZYME) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g liquid), 500 mgSee also 90283


J1460 Injection, gamma globulin, intramuscular, 1 cc (GAMASTAN, GAMASTAN S/D)


J1555 Injection, immune globulin (Cuvitru)See also 90284


J1556 Injection, immune globulin (Bivigam), 500 mg Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J1557 Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mgSee also 90283


J1559 Injection, immune globulin (Hizentra)See also 90284


J1560 Injection, gamma globulin, intramuscular, over 10 cc (1 unit= 10cc) (GAMASTAN, GAMASTAN S/D)




J1561 Injection, immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g. liquid), 500 mgSee also 90283 and 90284


J1566 Injection, immune globulin, intravenous, lyophilized (e.g powder), not otherwise specified, 500 mg (Only Carimune NF, and Gammagard S/D should be billed using this code)See also 90283


J1568 Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g. liquid), 500 mgSee also 90283


J1569 Injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g. liquid), 500 mgSee also 90283 and 90284


J1570 Injection, ganciclovir sodium, 500 mg (CYTOVENE, GANCICLOVIR SODIUM)



J1572 Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g. liquid), 500 mgSee also 90283


J1575 Injection, immune globulin/hyaluronidase, (Hyqvia), 100 mg immune globulin


J1595 Injection, glatiramer acetate, 20 mg (GLATOPA, GLATIRAMER, COPAXONE)


J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg (PANZYGA)See also 90283


J1602 Injection, golimumab, 1 mg, for intravenous use (Simponi Aria)


J1627 Injection, granisetron, extended-release, 0.1 mg (SUSTOL)



J1725 Injection, hydroxyprogesterone caproate, 1 mg (No longer payable by Medicare effective 7/1/17) - see Q9986 (Code deleted effective 12/31/17) - see J1726 (MAKENA)


J1726 Injection, hydroxyprogesterone caproate, (Makena), 10 mg (For billing prior 1/1/18 use J1725 or Q9986)


J1729 Injection, hydroxyprogesterone caproate, Not Otherwise Specified, 10 mg (For billing prior to 1/1/18 use J3490 or Q9985)


J1740 Injection, ibandronate sodium, 1 mg (BONIVA, IBANDRONATE)


J1743 Injection, idursulfase, 1 mg (Elaprase) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J1744 Injection, icatibant, 1 mg (ICATIBANT, FIRAZYR) Specialty Drug See Pharmacy Benefit tab.J1745 Injection, infliximab, excludes biosimilar, 10 mg

(Remicade)Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ1746 Injection, ibalizumab-uiyk, 10 mg (TROGARZO) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ1786 Injection, imiglucerase, 10 units (Cerezyme) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ1826 Injection, interferon beta-1a, 30 mcg (AVONEX) -see

also Q3027Specialty Drug See Pharmacy Benefit tab.

J1830 Injection, interferon beta-1B, 0.25 mg (BETASERON, EXTAVIA)


J1930 Injection, lanreotide, 1 mg (SOMATULINE DEPOT) Specialty Drug Medical Oncology -

CHEMO


J1931 Injection, laronidase, 0.1 mg (ALDURAZYME) Specialty Drug eviCore for delegated members; BCBSAZ for all other members



J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg (LUPRON DEPOT (3.75MG and 11.25MG), LUPRON DEPOT-PED (7.5MG, 11.25MG, 15MG, and 30MG)


CHEMO


J2182 Injection, mepolizumab, 1 mg (NUCALA) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2212 Injection, methylnaltrexone, 0.1 mg (RELISTOR) Specialty Drug See Pharmacy Benefit tab.J2323 Injection, natalizumab, 1 mg (TYSABRI) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ2326 Injection, nusinersen, 0.1 mg (SPINRAZA) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ2350 Injection, ocrelizumab, 1 mg (OCREVUS) Specialty Drug eviCore for delegated members;

BCBSAZ for all other membersJ2353 Injection, octreotide, depot form for intramuscular

injection, 1 mg (SANDOSTATIN LAR DEPOT)Specialty Drug



J2354 Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg (SANDOSTATIN, OCTREOTIDE ACETATE)


CHEMO


J2357 Injection, omalizumab, 5 mg (XOLAIR) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2430 Injection, pamidronate disodium, per 30 mg (PAMIDRONATE DISODIUM)



J2469 Injection, palonosetron HCl, 25 mcg (ALOXI, PALONSETRON)



J2502 Injection, pasireotide long acting, 1 mg (SIGNIFOR LAR) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2503 Injection, pegaptanib sodium, 0.3 mg (MACUGEN) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2504 Injection, pegademase bovine, 25 IU (All NDCs inactive as of 7/4/19) (ADAGEN)


J2505 Injection, pegfilgrastim, 6 mg (NEULASTA) Specialty Drug Medical Oncology -

SPORT


J2507 Injection, pegloticase, 1 mg (KRYSTEXXA) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2778 Injection, ranibizumab, 0.1 mg (LUCENTIS) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2786 Injection, reslizumab, 1 mg (CINQIAR) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2793 Injection, rilonacept, 1 mg (ARCALYST) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2796 Injection, romiplostim, 10 micrograms (NPLATE) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2820 Injection, sargramostim (GM-CSF), 50 mcg (LEUKINE) Specialty Drug Medical Oncology -

SPORT


J2840 Injection, sebelipase alfa, 1 mg (KANUMA) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J2860 Injection, siltuximab, 10 mg (SYLVANT) Specialty Drug Medical Oncology -

CHEMO


J2941 Injection, somatropin, 1 mg (HUMATROPE, NORDITROPIN, SAIZEN, ZORBTIVE, GENOTROPIN, SEROSTIM, OMNITROPE, ZOMACTON, NUTROPIN AQ)


J3060 Injection, taliglucerase alfa, 10 units (ELELYSO) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J3110 Injection, teriparatide, 10 mcg (FORTEO) Specialty Drug See Pharmacy Benefit tab.J3111 Injection, romosozumab-aqqg, 1 mg (EVENITY) Specialty Drug eviCore for delegated members;

BCBSAZ for all other members



J3245 Injection, tildrakizumab, 1 mg (ILUMYA) Specialty Drug PA required only for eviCore delegated members

J3262 Injection, tocilizumab, 1 mg (Actemra) Specialty Drug Medical Oncology -

CHEMO

BCBSAZ for all members and eviCore delegated members

J3285 Injection, treprostinil, 1 mg (REMODULIN, TREPROSTINIL)


J3304 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg (ZILRETTA)

Specialty Drug PA required only for eviCore delegated members

J3315 Injection, triptorelin pamoate, 3.75 mg (TRELSTAR) Medical Oncology - CHEMO


J3316 Injection, triptorelin, extended-release, 3.75 mg (TRIPTODUR)


J3357 Ustekinumab, for subcutaneous injection, 1 mg (STELARA)


J3358 Ustekinumab, for intravenous injection, 1 mg (For billing prior to 1/1/18 use Q9989) (STELARA)

Specialty Drug BCBSAZ for all members and eviCore delegated members

J3380 Injection, vedolizumab, 1 mg (ENTYVIO) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J3385 Injection, velaglucerase alfa, 100 units (VPRIV) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J3396 Injection, verteporfin, 0.1 mg (VISUDYNE) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J3397 Injection, vestronidase alfa-vjbk, 1 mg (MEPSEVII) Specialty Drug PA required only for eviCore delegated members

J3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes (LUXTURNA)


J3489 Injection, zoledronic acid, 1 mg (RECLAST, ZOLEDRONIC ACID)


SPORT


J3490 bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg See code Q5118 effective 10/01/2019.



J3490 Calaspargase pegol-mknl Medical Oncology - CHEMO


J3490 Gemcitabine HCL Medical Oncology - CHEMO


J3490 Levoleucovorin (KHAPZORY) Medical Oncology - CHEMO


J3490 Polatuzumab vedotin-piiq Medical Oncology - CHEMO


J3490 Rituximab-pvvr (RUXIENCE) Medical Oncology - CHEMO


J3490 Trastuzumab-anns Medical Oncology - CHEMO


J3490 Trastuzumab-qyyp Medical Oncology - CHEMO


J3490 defibrotide (DEFITELIO) 80MG/ML Solution J3490 Unclassified drugs


J3490 Intra-Articular Hyaluronan Injections (SYNOJOYNT) Specialty Drug PA required only for eviCore delegated members

J3490 pasireotide (SIGNIFOR) 0.3MG/ML Solution C9399 Unclassified drugs or biologicals


J3490 Sildenafil (REVATIO) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J3490 Unclassified Drugs - SPRAVATO (esketamine HCl) nasal solution


J3490 Unclassified drugs, NOT OTHERWISE CLASSIFIED Specialty Drug Medical Oncology -

CHEMO


J3590 bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg See code Q5118 effective 10/01/2019.





J3590 Calaspargase pegol-mknl Medical Oncology - CHEMO


J3590 Peginterferon, alfa-2a Medical Oncology - CHEMO


J3590 Polatuzumab vedotin-piiq Medical Oncology - CHEMO


J3590 Trastuzumab-anns Medical Oncology - CHEMO


J3590 Trastuzumab-qyyp Medical Oncology - CHEMO


J3590 ZOLGENSMA (onasemmogene abeparvovec-xioi) Kit J3590 Unclassified biologics


J3590 Ravulizumab-cwvz Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J3590 Romosozumab-aqqg Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J3590 elapegademase-ivlr (REVCOVI) 2.4MG/1.5ML Solution J3590 Unclassified biologics


J3590 pegvaliase-pqpz (PALYNZIQ) 2.5MG/0.5ML Solution Prefilled Syringe J3590 Unclassified biologics


J3590 Unclassified biologics, NOT OTHERWISE CLASSIFIED Specialty Drug Medical Oncology -

CHEMO


J7170 Injection, emicizumab-kxwh, 0.5 mg (HEMLIBRA) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J7175 Injection, factor X, (human), 1 IU (COAGADEX) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J7177 Injection, human fibrinogen concentrate (fibryga), 1 mg (Price is per 1mg. Product contains approximately 1 gram (900-1300mg)) (FIBRYGA)


J7178 Injection, human fibrinogen concentrate, not otherwise specified, 1 mg (Code Price is per 1 mg - RiaSTAP contains 900-1300 mg) (RIASTAP)


J7179 Injection, Von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:RCo (VONVENDI)


J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU (Code Price is per 1 IU - Corifact contains 1000-1600 Units) (CORIFACT)


J7181 Injection, factor XIII A-subunit, (recombinant), per IU (TRETTEN)


J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NOVOEIGHT), per IU


J7183 Injection, Von Willebrand factor complex (human), Wilate, 1 IU VWF:RCO


J7185 Injection, factor VIII (antihemophilic factor, recombinant) (XYNTHA), per IU


J7186 Injection, antihemophilic factor VIII/Von Willebrand factor complex (human), per factor VIII I.U. (ALPHANATE)


J7187 Injection, Von Willebrand factor complex (Humate-P), per IU, VWF:RCO (HUMATE-P)


J7188 Injection, factor VIII (antihemophilic factor, recombinant), (OBIZUR), per IU


J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 microgram (NOVOSEVEN-RT)


J7190 Factor VIII (antihemophilic factor [human]) per IU (HEMOFIL M, KOATE)


J7192 Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified (ADVATE, KOGENATE FS, RECOMBINATE)


J7193 Factor IX (antihemophilic factor, purified, non-recombinant) per IU (ALPHANINE SD, MONONINE)




J7194 Factor IX, complex, per IU (PROFILNINE) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J7195 Injection factor IX (antihemophilic factor, recombinant) per IU, not otherwise specified (BENEFIX, IXINITY)


J7198 Anti-inhibitor, per IU (FEIBA NF) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J7199 Hemophilia clotting factor, not otherwise classified (ESPEROCT)


J7200 Injection, factor IX, (antihemophilic factor, recombinant), RIXUBIS, per IU


J7201 Injection, factor IX, Fc fusion protein, (recombinant), ALPROLIX, 1 IU


J7202 Injection, factor IX, albumin fusion protein, (recombinant), IDELVION, 1 IU


J7203 Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (REBINYN), 1 iu


J7205 Injection, factor VIII, Fc fusion protein (recombinant), per IU (ELOCTATE)


J7207 Injection, factor VIII, (antihemophilic factor, recombinant), pegylated, 1 IU (ADYNOVATE)


J7208 Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. (JIVI)


J7209 Injection, factor VIII, (antihemophilic factor, recombinant), (NUWIQ), 1 IU


J7210 Injection, factor VIII, (antihemophilic factor, recombinant), (AFSTYLA), 1 IU


J7211 Injection, factor VIII, (antihemophilic factor, recombinant), (KOVALTRY), 1 IU


J7311 Injection, fluocinolone acetonide, intravitreal implant (RETISERT), 0.01 mg


J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg (OZURDEX)


J7313 Injection, fluocinolone acetonide, intravitreal implant (ILUVIEN), 0.01 mg


J7316 Injection, ocriplasmin, 0.125 mg (JETREA) Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J7318 Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (DUROLANE)


J7320 Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1 mg (Code re-used by CMS effective 1/1/17) (GenVisc 850 dose is 25 mg/2.5 mL) (Note: Total dose regimen = 3 - 5 injections)


J7321 Hyaluronan or derivative, Hyalgan or Supartz or Visco-3, for intra-articular injection, per dose (Hyalgan dose is 20 mg/2 mL, Supartz and Visco-3 dose is 25 mg/2.5 mL) (Note: Total dose regimen = 3 - 5 injections)


J7322 Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg (Code re-used by CMS effective 1/1/17) (For billing prior to 1/1/17 use J3490 or C9471 for OPPS billing) (Hymovis dose is 24 mg/3 mL) (Note: Total dose regimen = 2 injections)


J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (20 mg/2 mL) (Note: Total dose regimen = 3 injections)


J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (30 mg/2 mL) (Note: Total dose regimen = 3 - 4 injections)


J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg (For billing prior to 1/1/10 see J7322 for Synvisc and J3490 for Synvisc-One)


J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose




J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose (For billing prior to 1/1/15 use C9399 or J3490) (Dose 88 mg/4 mL) (Note: Total dose regimen = 1 dose) MONOVISC


J7328 Hyaluronan or derivative, GELSYN-3, for intra-articular injection, 0.1 mg


J7329 Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg (TRIVISC)


J7345 Aminolevulinic acid HCl for topical administration, 10% gel, 10 mg (AMELUZ)


J7999 Compounded drug, not otherwise classified (NDCs listed are for final compounded products only)


J9000 Injection, doxorubicin hydrochloride, 10 mg (ADRIAMYCIN, DOXORUBICIN HCL)



J9015 Injection, aldesleukin, per single-use vial (PROLEUKIN) Medical Oncology - CHEMO


J9017 Injection, arsenic trioxide, 1 mg (ARSENIC TRIOXIDE, TRISENOX)



J9019 Injection, asparaginase (Erwinaze), 1,000 IU Specialty Drug Medical Oncology -

CHEMO


J9022 Injection, atezolizumab, 10 mg (TECENTRIQ) Specialty Drug Medical Oncology -

CHEMO


J9023 Injection, avelumab, 10 mg (BAVENCIO) Specialty Drug Medical Oncology -

CHEMO


J9025 Injection, azacitidine, 1 mg (AZACITIDINE, VIDAZA) Medical Oncology - CHEMO


J9027 Injection, clofarabine, 1 mg (CLOLAR, CLOFARABINE) Specialty Drug Medical Oncology -

CHEMO


J9030 BCG live intravesical instillation, 1 mg (TICE BCG) Medical Oncology - CHEMO


J9032 Injection, belinostat, 10 mg (BELEODAQ) Medical Oncology - CHEMO


J9033 Injection, bendamustine HCl (Treanda), 1 mg Specialty Drug Medical Oncology -

CHEMO


J9034 Injection, bendamustine HCl (Bendeka), 1 mg Specialty Drug Medical Oncology -

CHEMO


J9035 Injection, bevacizumab, 10 mg (AVASTIN) Specialty Drug Medical Oncology -

CHEMO


J9036 Injection, bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mg



J9039 Injection, blinatumomab, 1 microgram (BLINCYTO) Specialty Drug Medical Oncology -

CHEMO


J9040 Injection, bleomycin sulfate, 15 units (BLEOMYCIN SULFATE)



J9041 Injection, bortezomib (VELCADE), 0.1 mg Medical Oncology - CHEMO


J9042 Injection, brentuximab vedotin, 1 mg (ADCETRIS) Medical Oncology - CHEMO


J9043 Injection, cabazitaxel, 1 mg (JEVTANA) Medical Oncology - CHEMO


J9044 Injection, bortezomib, not otherwise specified, 0.1 mg (BORTEZOMIB)



J9045 Injection, carboplatin, 50 mg (CARBOPLATIN, PARAPLATIN)





J9047 Injection, carfilzomib, 1 mg (KYPROLIS) Medical Oncology - CHEMO


J9050 Injection, carmustine, 100 mg (CARMUSTIN, BICNU) Medical Oncology - CHEMO


J9055 Injection, cetuximab, 10 mg (ERBITUX) Medical Oncology - CHEMO


J9057 Injection, copanlisib, 1 mg (ALIQOPA) Medical Oncology - CHEMO


J9060 Injection, cisplatin, powder or solution, per 10 mg (CISPLATIN)



J9065 Injection, cladribine, per 1 mg (CLADRIBINE) Medical Oncology - CHEMO


J9070 Cyclophosphamide, 100 mg (CYCLOPHOSPHAMIDE) Medical Oncology - CHEMO


J9100 Injection, cytarabine, 100 mg (CYTARABINE) Medical Oncology - CHEMO


J9118 Injection, calaspargase pegol-mknl, 10 units (ASPARLAS)



J9119 Injection, cemiplimab-rwlc, 1 mg (LIBTAYO) (Code effective 10/1/2019)



J9120 Injection, dactinomycin, 0.5 mg (COSMEGEN, DACTINOMYCIN)



J9130 Dacarbazine, 100 mg Medical Oncology - CHEMO


J9145 Injection, daratumumab, 10 mg (DARZALEX) Medical Oncology - CHEMO


J9150 Injection, daunorubicin, 10 mg Medical Oncology - CHEMO


J9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine (VYXEOS)



J9155 Injection, degarelix, 1 mg (FIRMAGON) Medical Oncology - CHEMO


J9171 Injection, docetaxel, 1 mg (DOCETAXEL, TAXOTERE) Medical Oncology - CHEMO


J9173 Injection, durvalumab, 10 mg (IMFINZI) Medical Oncology - CHEMO


J9176 Injection, elotuzumab, 1 mg (EMPLICITI) Medical Oncology - CHEMO


J9178 Injection, epirubicin HCl, 2 mg (EPIRUBICIN HCl, ELLENCE)



J9179 Injection, eribulin mesylate, 0.1 mg (HALAVEN) Medical Oncology - CHEMO


J9181 Injection, etoposide, 10 mg (ETOPOPHOS, ETOPOSIDE, TOPOSAR)



J9185 Injection, fludarabine phosphate, 50 mg (FLUDARABINE PHOSPHATE)



J9190 Injection, fluorouracil, 500 mg (ADRUCIL, FLUOROURACIL)



J9199 Injection, gemcitabine hydrochloride (INFUGEM), 200 mg



J9200 Injection, floxuridine, 500 mg (FLOXURIDINE) Medical Oncology - CHEMO


J9201 Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg (GEMCITABINE HCL)



J9202 Goserelin acetate implant, per 3.6 mg (ZOLADEX) Medical Oncology - CHEMO


J9203 Injection, gemtuzumab ozogamicin, 0.1 mg (MYLOTARG)



J9204 Injection, mogamulizumab-kpkc, 1 mg (POTELIGEO) Medical Oncology - CHEMO


J9205 Injection, irinotecan liposome, 1 mg (ONIVYDE) Medical Oncology - CHEMO




J9206 Injection, irinotecan, 20 mg (IRINOTECAN HCl, CAMPTOSAR



J9207 Injection, ixabepilone, 1 mg (IXEMPRA) Medical Oncology - CHEMO


J9208 Injection, ifosfamide, 1 gram (IFOSFAMIDE, IFEX) Medical Oncology - CHEMO


J9211 Injection, idarubicin hydrochloride, 5 mg (IDARUBICIN HCl, IDAMYCIN PFS)



J9214 Injection, interferon, alfa-2b, recombinant, 1 million units (INTRON A)


CHEMO


J9215 Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 IU (ALFERON N)


J9216 Injection, interferon, gamma-1b, 3 million units (ACTIMMUNE)


CHEMO


J9217 Leuprolide acetate (for depot suspension), 7.5 mg (LUPRON DEPOT 7.5MG, 22.5MG, 30MG, 45MG) (ELIGARD 30MG, 45MG)


CHEMO


J9218 Leuprolide acetate, per 1 mg Specialty Drug Medical Oncology -

CHEMO


J9225 Histrelin implant (VANTAS), 50 mg Medical Oncology - CHEMO


J9226 Histrelin implant (SUPPRELIN LA), 50 mg Specialty Drug eviCore for delegated members; BCBSAZ for all other members

J9228 Injection, ipilimumab, 1 mg (YERVOY) Specialty Drug Medical Oncology -

CHEMO


J9229 Injection, inotuzumab ozogamicin, 0.1 mg (BESPONSA) Medical Oncology - CHEMO


J9230 Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10 mg (MUSTARGEN)



J9245 Injection, melphalan hydrochloride, 50 mg (MELPHALAN HCl, EVOMELA, ALKERAN)



J9250 Methotrexate sodium, 5 mg (METHOTREXATE SODIUM)



J9260 Methotrexate sodium, 50 mg (METHOTREXATE SODIUM)



J9261 Injection, nelarabine, 50 mg (ARRANON) Medical Oncology - CHEMO


J9262 Injection, omacetaxine mepesuccinate, 0.01 mg (SYNRIBO)



J9263 Injection, oxaliplatin, 0.5 mg (OXALIPLATIN) Medical Oncology - CHEMO


J9264 Injection, paclitaxel protein-bound particles, 1 mg (ABRAXANE)



J9266 Injection, pegaspargase, per single dose vial (ONCASPAR)



J9267 Injection, paclitaxel, 1 mg (PACLITAXEL) Medical Oncology - CHEMO


J9268 Injection, pentostatin, per 10 mg (NIPENT) Medical Oncology - CHEMO


J9269 Injection, tagraxofusp-erzs, 10 micrograms (ELZONRIS) (code effective 10/1/2019)


CHEMO


J9271 Injection, pembrolizumab, 1 mg (KEYTRUDA) Medical Oncology - CHEMO


J9280 Injection, mitomycin, 5 mg (MITOMYCIN, MUTAMYCIN) Medical Oncology - CHEMO


J9285 Injection, olaratumab, 10 mg (LARTUVO) Medical Oncology - CHEMO




J9293 Injection, mitoxantrone hydrochloride, per 5 mg (MITOXANTRONE HCL)


CHEMO


J9295 Injection, necitumumab, 1 mg (PORTRAZZA) Medical Oncology - CHEMO


J9299 Injection, nivolumab, 1 mg (OPDIVO) Specialty Drug Medical Oncology -

CHEMO


J9301 Injection, obinutuzumab, 10 mg (GAZYVA) Medical Oncology - CHEMO


J9302 Injection, ofatumumab, 10 mg (ARZERRA) Medical Oncology - CHEMO


J9303 Injection, panitumumab, 10 mg (VECTIBIX) Medical Oncology - CHEMO


J9305 Injection, pemetrexed, 10 mg (ALIMTA) Medical Oncology - CHEMO


J9306 Injection, pertuzumab, 1 mg (PERJETA) Specialty Drug Medical Oncology -

CHEMO


J9307 Injection, pralatrexate, 1 mg (FOLOTYN) Medical Oncology - CHEMO


J9308 Injection, ramucirumab, 5 mg (CYRAMZA) Medical Oncology - CHEMO


J9310 Injection, rituximab, 100 mg (Code deleted effective 12/31/18) (RITUXAN)


J9311 Injection, rituximab 10 mg and hyaluronidase (RITUXAN HYCELA)


CHEMO


J9312 Injection, rituximab, 10 mg (RITUXAN) Specialty Drug Medical Oncology -

CHEMO


J9313 Injection, moxetumomab pasudotox-tdfk, 0.01 mg (LUMOXITI)


CHEMO


J9315 Injection, romidepsin, 1 mg (ROMIDEPSIN, ISTODAX) Medical Oncology - CHEMO


J9320 Injection, streptozocin, 1 gram (ZANOSAR) Medical Oncology - CHEMO


J9325 Injection, talimogene laherparepvec, per 1 million plaque forming units (IMLYGIC)



J9328 Injection, temozolomide, 1 mg (TEMODAR) Medical Oncology - CHEMO


J9330 Injection, temsirolimus, 1 mg (TEMSIROLIMUS, TORISEL)



J9340 Injection, thiotepa, 15 mg (THIOTPA, TEPADINA) Medical Oncology - CHEMO


J9351 Injection, topotecan, 0.1 mg (TOPOTECAN HCl, HYCAMTIN)



J9352 Injection, trabectedin, 0.1 mg (YONDELIS) Medical Oncology - CHEMO


J9354 Injection, ado-trastuzumab emtansine, 1 mg (KADCYLA) Specialty Drug Medical Oncology -

CHEMO


J9355 Injection, trastuzumab, excludes biosimilar, 10 mg (HERCEPTIN)



J9356 Injection, trastuzumab, 10 mg and Hyaluronidase-oysk (HERCEPTIN HYLECTA)



J9357 Injection, valrubicin, intravesical, 200 mg (VALSTAR, VALRUBICIN)



J9360 Injection, vinblastine sulfate, 1 mg (VINBLASTINE SULFATE)





J9370 Vincristine sulfate, 1 mg (VINCRISTINE SULFATE) Medical Oncology - CHEMO


J9371 Injection, vincristine sulfate liposome, 1 mg (MARQIBO) Specialty Drug Medical Oncology -

CHEMO


J9390 Injection, vinorelbine tartrate, per 10 mg (NAVELBINE, VINORELBINE TARTRATE)



J9395 Injection, fulvestrant, 25 mg (FULVESTRANT, FASLODEX)



J9400 Injection, ziv-aflibercept, 1 mg (ZALTRAP) Medical Oncology - CHEMO


J9600 Injection, porfimer sodium, 75 mg (PHOTOFRIN) Medical Oncology - CHEMO


J9999 dinutuximab (UNITUXIN) 3.5MG/ML Solution J9999. Not otherwise classified, antineoplastic drugs



J9999 Injection, gemcitabine hydrochloride (INFUGEM), 200 mg. See J9199, code effective 1/01/2020



J9999 Not otherwise classified, antineoplastic drugs Specialty Drug Medical Oncology -

CHEMO


Q2017 Injection, teniposide, 50 mg Medical Oncology - CHEMO


Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose (For billing prior to 4/1/18 use J9999 or C9399 for OPPS billing) (Code Price is for drug ONLY) (Code re-used by CMS) (YESCARTA)


Q2042 Tisagenlecleucel, up to 250 million car-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion (For billing prior to 1/1/18 use J9999 or C9399 for OPPS billing) (Code re-used by CMS 1/1/18) (Effective 6/1/18 use NDC level pricing for appropriate reimbursement based on NDC submitted) (Code deleted effective 12/31/18) (KYMRIAH)


Q2043 Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Code Price is per 250 mL) (Provenge)


CHEMO


Q2049 Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg (All NDCs inactive as of 3/7/2019)



Q2050 Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg (Doxil, Doxorubicin HCL)



Q3028 Injection, interferon beta-1a, 1 mcg for subcutaneous use (REBIF)


Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) (for renal dialysis facilities and hospital use) (Procrit, Epogen)


Q5101 Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 microgram


SPORT


Q5102 Injection, infliximab, biosimilar, 10 mg (Code deleted effective 3/31/18) - see Q5103 and Q5104


Q5103 Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg Specialty Drug eviCore for delegated members; BCBSAZ for all other members

Q5104 Injection, infliximab-abda, biosimilar, (Renflexis), 10 mg Specialty Drug eviCore for delegated members; BCBSAZ for all other members

Q5106 Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-esrd use), 1000 units


SPORT




Q5107 Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mg Medical Oncology - CHEMO


Q5108 Injection, pegfilgrastim-jmdb, biosimilar, (Fulphila), 0.5 mg


SPORT


Q5110 Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 microgram


SPORT


Q5111 Injection, Pegfilgrastim-cbqv, biosimilar, (Udenyca), 0.5 mg



Q5112 Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg



Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg



Q5114 Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg Medical Oncology - CHEMO


Q5115 Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg Medical Oncology - CHEMO


Q5116 Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg



Q5118 Injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg



Q9986 Injection, hydroxyprogesterone caproate (Makena), 10 mg (Code deleted effective 12/31/17) - see J1726


S0145 Injection, pegylated interferon alfa-2a, 180 mcg per mL (Code Price is per 180 mcg) (Pegasys)



S0148 Injection, pegylated interferon alfa-2b, 10 mcg (Pegintron)



S9562 Home injectable therapy, palivizumab, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (SYNAGIS)


eviCore is a separate, independent company that provides precertification services to BCBSAZ providers and members.

CPT® (Current Procedural Terminology) codes are © 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Blue Cross, Blue Shield, the Cross and Shield Symbols, Federal Employee Program, and FEP are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

D24764 04/2020 Page 16 of 21 Pharmacy Benefit - Specialty Medication List

Pharmacy BenefitSpecialty Medication ListRevised 4/1/2020

Member cost share/out-of-pocket costMost BCBSAZ Members • Standard Pharmacy Plans: Specialty copay levels (A, B, C, or D) applies.• Qualified Health Plans: Specialty tier applies.

This list applies to members with plans that include pharmacy benefits administered by Blue Cross® Blue Shield® of Arizona (BCBSAZ).

This list does not does not apply to the following plans: Federal Employee Program® (FEP®) plans Medicare Advantage (MA) plans Employer-sponsored plans in our Corporate Health Services (CHS) program Plans offered or administered by other Blue Cross and/or Blue Shield plans Certain employer-sponsored health plans with customized benefits and prior authorization requirements ADOA State of Arizona (group 030855) City of Phoenix (groups 040000 and 040004) Knight Transportation, Inc (group 029653) Northwest Arizona Employee Benefit Trust (group 037461) OB Sports Golf Management, LLC (group 038043) Teamsters (groups 031843 and 031844)

For benefits and eligibility, or to inquire about prior authorization requirements for specialty medications not listed here or for one of the exempt plans listed above, you can call the pharmacy benefit manager (PBM) or administrator on the member ID card.

This list pertains to specialty medications that can be administered by oneself and are covered under the pharmacy benefit , such as capsules, tablets, topicals, and some nasal sprays and injectables. This list is subject to change at any time without notice.

For specialty medications that are covered under the medical benefit, click here.

Filling specialty medications covered under the pharmacy benefit Optum Specialty Pharmacy is our exclusive specialty pharmacy. You can call Optum Specialty Pharmacy at 1-877-850-7071 to order the prescription. Members should call Optum Specialty Pharmacy to establish service.

Requesting prior authorizationMost BCBSAZ membersFor most members, BCBSAZ handles the prior authorization requests. You can do either of the following:• Use the online request tool in the secure provider portal at azblue.com/providers > Practice Management > Precertification > BCBSAZ Members-Requests for 2020. In the tool, be sure to select "Pharmacy" for your request. • Fax a prior authorization request to BCBSAZ Clinical Therapeutics Department at 602-864-3126.

Important: Chart notes must be included with your request.

Questions?For benefits and eligibility, or to inquire about prior authorization requirements for specialty medications not listed here, you can call the pharmacy benefit manager (PBM) or administrator on the member ID card. For most BCBSAZ members, you can call 1-866-325-1794.


Drug Name Description Route of Administration

Prior Authorization

Required

Specialty Copay Level

Actemra tocilizumab subcutaneous Yes DActhar corticotropin injection Yes CAdcirca tadalafil oral tablet Yes Dadefovir dipivoxil (generic for Hepsera) adefovir dipivoxil oral tablet No AAdempas riociguat oral tablet Yes DAimovig erenumab-aooe subcutaneous Yes DAjovy fremanezumab-vfrm subcutaneous Yes DAlyq (generic for Adcirca) tadalafil oral tablet Yes DAmpyra dalfampridine er oral tablet Yes CArikayce amikacin sulfate liposome inhalation Yes DAubagio teriflunomide oral tablet Yes BAvonex interferon beta-1a intramuscular Yes BAzilect rasagiline mesylate oral tablet No CBaraclude entecavir oral solution No BBaraclude entecavir oral tablet No DBenlysta belimumab subcutaneous Yes DBetaseron interferon beta-1b subcutaneous Yes BBethkis tobramycin inhalation No BBuphenyl sodium phenylbutyrate oral powder, tablet No BCablivi caplacizumab-yhdp injection Yes DCarbaglu carglumic acid oral tablet Yes DCayston aztreonam lysine inhalation Yes CCerdelga eliglustat tartrate oral capsule Yes DCholbam cholic acid oral capsule Yes CCimzia certolizumab pegol subcutaneous Yes Bcinacalcet (generic for Sensipar) cinacalcet hydrochloride oral tablet No CClovique trientine hydrochloride oral capsule Yes CCopaxone glatiramer acetate subcutaneous Yes BCopegus ribavirin oral tablet No DCosensi amlodipine besylate-celecoxib oral tablet Yes CCosentyx secukinumab subcutaneous Yes DCrinone progesterone vaginal Yes Ccyclosporine (generic for Neoral) cyclosporine modified oral capsule, solution No ACystadane betaine oral solution No CCystagon cysteamine bitartrate oral capsule No CDaklinza daclatasvir dihydrochloride oral tablet Yes Ddalfampridine ER (generic for Ampyra) dalfampridine er oral tablet Yes Cdeferasirox (generic for Jadenu) deferasirox oral tablet Yes DDiacomit stiripentol oral capsule, packet Yes Cdofetilide (generic for Tikosyn) dofetilide oral capsule No ADoptelet avatrombopag maleate oral tablet Yes Cdoxercalciferal (generic for Hectorol) doxercalciferal oral capsule No ADroxia hydroxyurea oral capsule Yes BDupixent dupilumab subcutaneous Yes DEgrifta tesamorelin acetate subcutaneous Yes DEgrifta SV tesamorelin acetate subcutaneous Yes D



Prior Authorization

Required


Emgality galcanezumab-gnlm subcutaneous Yes DEmsam selegiline transdermal No DEnbrel etanercept subcutaneous Yes Dentecavir (generic for Baraclude) entecavir oral tablet No AEpclusa sofosbuvir - velpatasvir oral tablet Yes BEpivir HBV lamivudine oral solution No BEpivir HBV lamivudine oral tablet No DEsbriet pirfenidone oral capsule, tablet Yes DExjade deferasirox oral tablet Yes DExtavia interferon beta-1b subcutaneous Yes BFasenra benralizumab subcutaneous Yes DFerriprox deferiprone oral solution, tablet Yes DFirazyr icatibant acetate subcutaneous Yes DFirdapse amifampridine phosphate oral tablet Yes DForteo teriparatide subcutaneous Yes BFosrenol lanthanum carbonate oral chewable tablet No DFuzeon enfuvirtide subcutaneous Yes AGalafold migalastat HCl oral capsule Yes DGattex teduglutide subcutaneous Yes Dgengraf (generic for Neoral) cyclosporine modified oral capsule, solution No AGenotropin somatropin subcutaneous Yes DGilenya fingolimod hcl oral capsule Yes BGlatiramer glatiramer acetate subcutaneous Yes BGlatopa glatiramer acetate subcutaneous Yes BHaegarda c1 esterase inhibitor subcutaneous Yes DHarvoni ledipasvir - sofosbuvir oral tablet Yes BHectorol doxercalciferal oral capsule No CHepsera adefovir dipivoxil oral tablet No DHetlioz tasimelteon oral capsule Yes DHumatrope somatropin subcutaneous Yes DHumira adalimumab subcutaneous Yes Bicatibant acetate (generic for Firazyr) icatibant acetate subcutaneous Yes DIlaris canakinumab subcutaneous Yes DIncrelex mecasermin subcutaneous Yes DJadenu deferasirox oral granules, tablet Yes DJatenzo testosterone undecanoate oral capsule Yes CJuxtapid lomitapide mesylate oral capsule Yes DJynarque tolvaptan oral tablet Yes CKalbitor ecallantide subcutaneous Yes DKalydeco ivacaftor oral tablet Yes DKeveyis dichlorphenamide oral tablet Yes DKevzara sarilumab subcutaneous Yes DKineret anakinra subcutaneous Yes CKitabis tobramycin inhalation Yes CKorlym mifepristone oral tablet Yes CKuvan sapropterin dihydrochloride oral tablet, oral powder packets Yes DKynamro mipomersen sodium subcutaneous Yes Dlamivudine HBV (generic for Epivir HBV) lamivudine oral tablet No A



Prior Authorization

Required


lanthanum (generic for Fosrenol) lanthanum carbonate oral chewable tablet No Bledipasvir/sofosbuvir ledipasvir - sofosbuvir oral tablet Yes BLetairis ambrisentan oral tablet Yes DLupron Depot leuprolide acetate intramuscular Yes DLupron Depot-PED leuprolide acetate intramuscular Yes DMakena hydroxyprogesterone caproate intramuscular Yes DMavenclad cladribine oral tablet Yes DMavyret glecaprevir - pibrentasvir oral tablet Yes BMayzent siponimod fumarate oral tablet Yes DMesnex mesna oral tablet No Cmiglustat (generic for Zavesca) miglustat oral capsule Yes DModeriba ribavirin oral tablet No AModeriba PAK ribavirin oral tablet No DMulpleta lusutrombopag oral tablet Yes CMyalept metreleptin subcutaneous Yes DMyfortic mycophenolate sodium oral tablet No DNatpara parathyroid hormone subcutaneous Yes DNebupent pentamidine isethionate inhalation No BNeoral cyclosporine modified oral capsule, solution No DNeupro rotigotine transdermal No CNorditropin somatropin subcutaneous Yes DNorthera droxidopa oral capsule Yes DNucala mepolizumab subcutaneous Yes DNutropin AQ Nuspin somatropin subcutaneous Yes BOcaliva obeticholic acid oral tablet Yes DOfev nintedanib esylate oral capsule Yes DOlumiant baricitinab oral tablet Yes DOlysio simeprevir sodium oral capsule Yes DOmnitrope somatropin subcutaneous Yes DOpsumit macitentan oral tablet Yes DOrencia abatacept subcutaneous Yes DOrenitram treprostinil diolamine oral tablet Yes DOrfadin nitisinone oral capsule, suspension Yes DOrkambi lumacaftor - ivacaftor oral tablet, granules Yes COtezla apremilast oral tablet Yes BOxbryta voxelotor oral tablet Yes COxervate cenegermin-bkbj ophthalmic solution Yes DPalynziq pegvaliase-pqpz subcutaneous Yes CPegasys peginterferon alfa-2a subcutaneous No BPeg-Intron, Pegintron peginterferon alfa-2b subcutaneous No Bpentamidine (generic for Nebupent) pentamidine isethionate inhalation No BPlegridy peginterferon beta-1a subcutaneous Yes BPraluent alirocumab subcutaneous Yes BPretomanid pretomanid oral tablet Yes CPrevymis letermovir oral tablet Yes DProcysbi cysteamine bitartrate oral capsule No CProlia denosumab subcutaneous Yes D

Promacta eltrombopag olamineoral tablet,

oral powder for suspension Yes CPulmozyme dornase alfa inhalation No B



Prior Authorization

Required


rasagiline mesylate (generic for Azilect) rasagiline mesylate oral tablet No ARavicti glycerol phenylbutyrate oral solution Yes DRebetol ribavirin oral capsule, solution No DRebif interferon beta-1a subcutaneous Yes BRelistor methylnaltrexone bromide subcutaneous Yes CRepatha evolocumab subcutaneous Yes BRevatio sildenafil citrate oral suspension, tablet Yes DReyvow lasmiditan succinate oral tablet Yes CRibasphere ribavirin oral tablet No ARibasphere ribavirin oral capsule No CRibasphere Ribatab ribavirin oral tablet No DRibavirin ribavirin oral tablet No ARibavirin ribavirin oral capsule No CRinvoq upadacitinib oral tablet Yes CRuzurgi amifampridine oral tablet Yes CSabril vigabatrin oral powder, tablet Yes BSaizen somatropin subcutaneous Yes DSamsca tolvaptan oral tablet Yes CSandimmune cyclosporine oral solution No BSandimmune cyclosporine oral capsule No DSensipar cinacalcet hydrochloride oral tablet No CSerostim somatropin subcutaneous Yes Bsildenafil citrate (generic for Revatio) sildenafil citrate oral tablet Yes ASiliq brodalumab subcutaneous Yes DSimponi golimumab subcutaneous Yes BSkyrizi risankizumab-rzaa injection Yes Dsofosbuvir/velpatasvir sofosbuvir - velpatasvir oral tablet Yes BSomavert pegvisomant subcutaneous No CSovaldi sofosbuvir oral tablet Yes DStelara ustekinumab subcutaneous Yes BStrensiq asfotase alfa subcutaneous Yes DSucraid sacrosidase oral solution Yes DSymdeko tezacaftor - ivacaftor oral tablet Yes DSynarel nafarelin acetate nasal Yes CSyprine trientine hydrochloride oral capsule Yes CTadalafil (generic for Adcirca) tadalafil oral tablet Yes DTakhzyro lanadelumab-flyo subcutaneous Yes DTaltz ixekizumab subcutaneous Yes DTecfidera dimethyl fumarate oral capsule Yes BTechnivie ombitasvir - paritaprevir - ritonavir oral tablet Yes DTegsedi inotersen subcutaneous Yes Dtetrabenazine (generic for Xenazine) tetrabenazine oral tablet Yes ATikosyn dofetilide oral capsule No CTobi tobramycin inhalation Yes CTobi Podhaler tobramycin inhalation Yes CTobramycin tobramycin inhalation Yes CTracleer bosentan oral tablet Yes DTremfya guselkumab subcutaneous Yes Btrientine trientine hydrochloride oral capsule Yes C



Prior Authorization

Required


Trikafta elexacaftor-tezacaftor-ivacaftor oral tablet Yes DTymlos abaloparatide subcutaneous Yes BTyvaso treprostinil inhalation Yes DUbrelvy ubrogepant oral tablet Yes DUptravi selexipag oral tablet Yes DValcyte valganciclovir oral tablet No DValcyte valganciclovir hydrochloride oral solution No Cvalganciclovir valganciclovir oral tablet No Avalganciclovir valganciclovir hydrochloride oral solution No AVemlidy tenofovir alafenamide fumarate oral tablet No BVentavis iloprost inhalation Yes D

Viekira Pakdasabuvir - ombitasvir - paritaprevir - ritonavir oral tablet Yes D

Viekira XRdasabuvir - ombitasvir - paritaprevir - ritonavir oral tablet Yes D

vigabatrin vigabatrin oral powder Yes Bvigadrone vigabatrin oral powder Yes BVivitrol naltrexone intramuscular No BVosevi sofosbuvir - velpatasvir - voxilaprevir oral tablet Yes DVumerity diroximel fumarate oral capsule Yes CVyndamax tafamidis oral capsule Yes DVyndaqel tafamidis maglumine oral capsule Yes DWakix pitolisant oral tablet Yes DXeljanz tofacitinib citrate oral tablet Yes DXeljanz XR tofacitinib citrate er oral tablet Yes DXenazine tetrabenazine oral tablet Yes DXermelo telotristat etiprate oral tablet Yes DXolair omalizumab subcutaneous, prefilled syringe Yes DXuriden uridine triacetate oral granules Yes DXyrem sodium oxybate oral solution Yes DZavesca miglustat oral capsule Yes DZepatier elbasvir - grazoprevir oral tablet Yes DZomacton somatropin subcutaneous Yes DZorbtive somatropin subcutaneous Yes CZortress everolimus oral tablet No C

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