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PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYLast update: February 2021Background:HCPCS codes (J-codes) can be administered through a member’s medical or pharmacy benefit. A few important notes:If administered through the Pharmacy benefit, the drug must be obtained through Accredo Specialty Pharmacyunless the drug is a “limited distribution” drug and then the pharmacy through whom it can be obtained is noted below. If the code you are looking for is not found on this list, please search by drug name (brand name) here AND on thePharmacy Prior Authorization list found onhttps://main.myconnecticare.com/ la en J3490, J3590 and J9999 are miscellaneous codes assigned to drugs that do not have a unique code assigned.Please search by drug brand name. This list is subject to change on a routine basis.* Please note, the list is sorted by Drug Name.To see if a specific drug is on this list, click on a letter and browse the table alphabetically.A B C D E F G H I J K L M N O P Q R S T U V W X Y ZOr, click on thisSearchCodebutton and enter the name of the drug in the pop-up task pane.Drug Name(Brand/Generic)J9264Abraxane (paclitaxel proteinbound)J3262Actemra (tocilizumab)J9216Actimmune (interferon, gamma1b)J0791Adakveo (crizanlizumab-tmca)J2062Adasuve (loxapine for inhalation)J9042Adcetris (brentuximab vedotin)J9000Adriamycin (doxorubicin)J9190Adrucil (fluorouracil)J7192Advate (factor VIII)J7207Adynovate (factor VIII)J7210Afstyla (factor VIII)J3031Ajovy (fremanezumab-vfrm)Limited distributionPharmaciesSeagen SecureBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 1 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug nosetron)J1931Aldurazyme (laronidase)J9215Alferon (Interferon Alfa-N3)J9305Alimta (pemetrexed)J9057Aliqopa (Copanlisib)J9245Alkeran (melphalan)J7186Alphanate (Factor VIII/VWF)J7193AlphaNine SD (Factor IX)J7201Alprolix (Factor IX)J2469Aloxi (palonosetron HCl)J0364Apokyn (apomorphine HCl)J0256Aralast (Alpha-1 proteinaseinhibitor)J2793Arcalyst (rilonacept)J2430Aredia (Pamidronate Disodium)J9261Arranon (nelarabine)J9302Arzerra (ofatumumab)J1554Asceniv (immune globulin)J9118Asparlas (calaspargase pegolmknl)J9035Avastin (bevacizumab)J3145Aveed (testosteroneundecanoate)Q5121Avsola (infliximab-axxq,biosimilar)A9590Azedra (iodine i-131 iobenguane)Limited distributionPharmaciesAcaria, CVS/ CareMark,Diplomat, PrimeTherapeutics, iCore,WalgreenBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 2 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J3490/C9399Barhemsys (amisulpride)J9023Bavencio (avelumab)J3490/C9462Baxdela (delafloxacin)J7194Bebulin (Factor IX Complex)J9032Beleodaq (belinostat)J9036Belrapzo (bendamustinehydrochloride)J9034Bendeka (bendamustine HCl)J7195BeneFIX (Factor IX recombinant)J0490Benlysta (belimumab)J0179Beovu (brolucizumab-dbll)J0597Berinert (C-1 esterase inhibitor)J9229Besponsa (inotuzumabozogamicin)J9050BICNU (carmustine)J9037Blenrep (belantamab mafodotinblmf)J9040Bleomycin (bleomycin sulfate)J9039Blincyto (blinatumomab)J1740Boniva (ibandronate sodium)J0585Botox (onabotulinumtoxinA)J0567Brineura (cerliponase alfa)J0594Busulfex (Busulfan)J3590/C9047Cablivi (caplacizumab-yhdp)J0202Campath (alemtuzumab)J9206Camptosar (irinotecan)Limited distributionPharmaciesBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 3 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J9045Carboplatin (carboplatin)J1786Cerezyme (imiglucerase)J0717Cimzia (certolizumab pegol)J2786Cinqair (reslizumab)J0598Cinryze (C1 esterase inhibitor)J0185Cinvanti (aprepitant)J9060Cisplatin (cisplatin)J9065Cladribine (cladribine)J9027Clolar (clofarabine)J7175Coagadex (factor X, human)Q9977Compounded Drugs, NOSJ7180Corifact (factor XIII)J9120Cosmegen (dactinomycin)J01833Cresemba (isavuconazoniumsulfate)J0584Crysvita (burosumab-twza)J1555Cuvitru (IVIG subcutaneous)J9070CyclophosphamideJ9308Cyramza acogen (decitabine)J9348/J9999/C9399Danyelza (naxitamab-gqgk)J9145Darzalex (daratumumab)J9144Darzalex Faspro (daratumumaband hyaluronidase-fihj)Limited distributionPharmaciesProfessional HomecareBiologicsBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 4 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J9150DaunorubicinJ1096Dextenza (dexamethasone)J1095Dexycu (dexamethasone)Q2050Doxil (doxorubicin hydrochloride,liposomal)J7318Durolane (Hyaluronan orderivative)J7351Durysta (bimatoprost,intracameral implant)J0586Dysport (abobotulinumtoxinA)J3590/C9399Egrifta (tesamorelin)J1743Elaprase (idursulfase)J3060Elelyso (taliglucerase alfa)J9175Elliotts’ B SolutionJ7205Eloctate (Factor VIII recombinant)J9263Eloxatin (oxaliplatin)J9269Elzonris (tagraxofusp-erzs)J1453Emend (Fosaprepitant)J9176Empliciti (elotuzumab)J9358Enhertu (fam-trastuzumabderuxtecan-nxki)J3380Entyvio (vedolizumab)J9178EpirubicinJ9055Erbitux (cetuximab)J7204Esperoct (factor viii,antihemophilic factor(recombinant), glycopegylatedexei)Limited distributionPharmaciesCVS/CareMark,Prescription Solutions,Right Source, WalgreenDohmenBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 5 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J9019Erwinaze (asparaginase)J7323Euflexxa (Hyaluronan orderivative)J3111Evenity (romosozumab-aqqg)J9246Evomela (Melphalan)J1428Exondys 51 (eteplirsen)J0178Eylea (Aflibercept)J0180Fabrazyme (agalsidase beta)J7194Factor IXJ7190-J7192Factor VIII antihemophilic factorJ7180Factor XIIIJ0517Fasenra (benralizumab)J9395Faslodex (fulvestrant)J7198Feiba NF (Anti-inhibitor)J1950 or J1951Fensolvi (Leuprolide)J0693Fetroja (cefiderocol)J1744Firazyr (icatibant)J9155Firmagon (degarelix)J1325Flolan (epoprostenol)J9200FloxuridineJ9185Fludarabine (fludarabinephosphate)J9307Folotyn (pralatrexate)Q5108Fulphila (pegfilgrastim-jmdb)J9210Gamifant (emapalumab-izsg)J3490/C9399Gattex (teduglutide)Limited distributionPharmaciesProfessional HomecareBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 6 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J9301Gazyva (obinutuzumab)J7326Gel-One (Hyaluronan orderivative)J7328Gelsyn-3 (Hyaluronan orderivative)J9201Gemcitabine hydrochlorideJ7320GenVisc 850 (Hyaluronan orderivative)J0223Givlaari (givosiran)J0257Glassia (alpha-1-proteinaseinhibitor–human)J1447Granix (tbo-filgrastim)J0599Haegarda (c-1 esterase inhibitor,human)J9179Halaven (eribulin mesylate)J7192Helixate (antihemophilic factor,recombinant)J7170Hemlibra (emicizumab-kxwh)J7190Hemofil M (factor VIIIantihemophilic factor, human)J1573-IV formulaJ1571-IM formulaHepagam B (Hepatitis B immuneglobulin)J9355Herceptin (trastuzumab)J9356Herceptin Hylecta (trastuzumaband hyaluronidase-oysk)Q5113Herzuma (trastuzumab-pkrb)J1559Hizentra (IVIG)J0800HP Acthar (corticotropin)J7187Humate-P (Von Willebrand factor)J7321Hyalgan (hyaluronan orderivative)Limited distributionPharmaciesBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 7 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J9351Hycamtin (topotecan)J7322Hymovis (hyaluronan orderivative)J1575Hyqvia (IVIG subcutaneous)J9211Idamycin (idarubicinhydrochloride)J7202Idelvion (factor IX, albumin fusionprotein, recombinant)J9208Ifex (ifosfamide)J0638Ilaris (canakinumab)J3245Ilumya (tildrakizumab)J7313Iluvien (fluocinolone acetonideintravitreal implant)J9173Imfinzi (durvalumab)J9325Imlygic (talimogenelaherparepvec)Q5103Inflectra (infliximab-dyyb)J9198Infugem (gemcitabinehydrochloride)J9214Intron-A (interferon alfa-2b)J3490Iprivask (desirudin)J9315Istodax (romidepsin)J1556 BivigamJ1566 CarimuneJ0850 CytogamJ1572 FlebogammaJ1569 GammagardJ1557 GammaplexJ1561 GamunexJ1568 OctagamJ1599 PanzygaJ1459 PrivigenIVIG (Immune Globulin liquid)J1566IVIG (Immune Globulin powder)Limited distributionPharmaciesBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 8 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J9207Ixempra (ixabepilone)Q5109Ixifi (infliximab-qbtx, biosimilar)J7195Ixinity (factor IX recombinant)J9281Jelmyto (mitomycin)J7316Jetrea (ocriplasmin)J9043Jevtana (cabazitaxel)J7208Jivi (Antihemophilic Factor,Recombinant (pegylated-auci)J9354Kadcyla (ado-trastuzumabemtansine)J1290Kalbitor (ecallantide)Q5117Kanjinti (trastuzumab-anns,biosimilar)J2840Kanuma (sebelipase alpha)J9271Keytruda (pembrolizumab)J0642Khapzory (levoleucovorin)J7190Koate (Factor VIII)J7192Kogenate FS (factor VIII,antihemophilic)J7211Kovaltry (factor VIII,antihemophilic)J2507Krystexxa (pegloticase)Q2042Kymriah (tisagenlecleucel)J9047Kyprolis (carfilzomib)J9285Lartruvo (olaratumab)J0202Lemtrada (alemtuzumab)J0640Leucovorin calciumJ2820Leukine (sargramostim GM-CSF)Limited distributionPharmaciesBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 9 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J0641LEVOleucovorin calciumJ9119Libtayo (cemiplimab-rwlc)Q2049Lipodox (doxorubicinhydrocholoride, liposomal)J2778Lucentis (ranibizumabIntravitreal)J0221Lumizyme (alglucosidase alfa)J9313Lumoxiti (moxetumomabpasudotox-tdfk)A9513Lutathera (lutetium lu 177,dotatate, therapeutic)J3398Luxturna (voretigene neparvovecrzyl)J2503Macugen (pegaptanib sodium)J9371Marqibo (vincristine sulfateliposome)J9245MelphalanJ3397Mepsevii (vestronidase alfa-vjbk)J9209MesnaJ9293MitoxantroneJ9349Monjuvi (tafasitamab-cxix)J7190Monoclate P (antihemophilicfactor)J7193Mononine (Factor IX,antihemophilic factor, purified,non-recombinant)J7327Monovisc (hyaluronan orderivative)J2562Mozobil (plerixaflor)J9280Mutamycin (mitomycin)Q5107Mvasi (bevacizumab-awwb.biosimilar)Limited distributionPharmaciesBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 10 of /pharmacypolicy.aspx

PHARMACY J-CODESPRIOR AUTHORIZATION LISTCOMMERCIAL MEMBERS ONLYCodeDrug Name(Brand/Generic)J9203Mylotarg (gemtuzumabozogamicin)J0587Myobloc (rimabotulinumtoxinB)J1458Naglazyme (galsulfase)J9390Navelbine (vinorelbine tartrate)J2505Neulasta (pegfilgrastim)J1442Neupogen (filgrastim)J9268Nipent (pentostatin)Q5110Nivestym (filgrastim-aafi)J7182Novoeight (factor VIII,antihemophilic factor,recombinant)J7189Novoseven (antihemophilic factorviia)J2796Nplate (romiplostim)J2182Nucala (mepolizumab)J0485Nulojix (belatacept)J7209Nuwiq (factor VIII, antihemophilicfactor, recombinant)Q5122Nyvepria (pegfilgrastim-apgf)J7188Obizur (antihemophilic factor VIII)J2350Ocrevus (ocrelizumab)Q5114Ogivri (trastuzumab-dkst,biosimilar)J9266Oncaspar (pegaspargase)J9205Onivyde (irinotecan liposome)J0222Onpattro (patisiran)Q5112Ontruzant (trastuzumab-dttb)Limited distributionPharmaciesBack to TopPharmacy HCPCS Codes Prior Authorization List – Commercial Members Only Page 11 of /pharmacypolicy.aspx