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Injectable and Oncology MedicationsAdministered by ProviderAuthorization Required ListNot related to bleeding and clotting disordersFor CareOregon Advantage and OHP membersRevised 6/1/2021INSTRUCTIONS FOR USE: This list contains Injectable Medications billed under the Medical Benefit that REQUIRE AUTHORIZATION. Always search byJ-Code AND by Drug Name because J-Codes change. Note: See Advantage and OHP columns for pertinent information.Prior Authorization Request forms can be found at aspx All Medicare Advantage Home Infusion Requests require review (initiated with DME/Home Infusion Department) regardless of PAdesignation of drug. Most, but not all, home infusion drugs are covered through Part D (pharmacy). This document should NOT be used for: hemophilia/factor/bleeding products OR self-administered drugs(For Medicaid, CareOregon requirements for Buy and Bill vs specialty pharmacy dispensing will depend onCCO-specific policies). VACCINES are NOT included in this document. A separate document on our website provides information regarding vaccine coverage.Common vaccines discussed in that document includes: Zostavax, Shingrix, Gardasil, Pneumovax, and Prevnar. If the drug is NOT found on this list AND will be Buy and Bill (Supplied and billed under the Medical Benefit by the Provider) then itdoes NOT require authorization. EXCEPTION: New drugs to the market not found on this list. Dump Codes C9399, J3590and J9999 require Prior Authorization for ANY medication being billed under them whether listed below or not. J3490 (unclassified drugs): Should only be used for drugs without a more specific code. Authorization only required IFdrug name is on the list below. Always use the most active code based on date of service and CMS HCPCS codes.315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND NAME(S)(Provided for reference onlyandare not all-inclusive)AUTHORIZATION REQUIREDAdvantage (Plus)MembersOHP MembersJ0129AbataceptOrenciaYesSQ- Med D onlyIV-PA RequiredYesJ0586J0135J9354J0178Abobotulinumtoxin KadcylaEyleaYesYes- Part D onlyYesYes- ST req'd(Avastin)YesYesYesYesJ0180J3490Agalsidase betaAlbiglutideFabrazymeTanzeumYesYes- Part D onlyYesYes- mtuzumabAlgluceraseAlglucosidase alfaAlglucosidase losYesYesYesYesYes- Part D onlyYesYesYesYesYes- PharmacyBenefit (nonformulary)315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND NAME(S)AUTHORIZATION REQUIREDJ7352J3490AfamelanotideAlirocumab(Provided for reference onlyandare not J3450J0365J9019J0401Alpha-1 Proteinase InhibitorAlpha-1 Proteinase Inhibitor (human)Alprostadil, injectionAlprostadil, urethral suppositoryAnakinraAprotininAsparaginase ErwiniaAripiprazole, injection extended releaseProlastinGlassiaCaverject, EdexMuseKineretTrasylolErwinazeAbilify MaintenaJ1944Aripiprazole, injection extended releaseAristadaYesYes (excluded)Covered byDMAP J1943Aripiprazole, injectionAristada InitioYesYes (excluded)Covered byDMAP J3490,J3590Asfotase alfaStrensiqYes- Part D onlyYes- PharmacyBenefitJ9022AtezolizumabTecentriqYesYes315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416Advantage (Plus)MembersOHP MembersYesYes- Part D onlyYesYes- PharmacyBenefitYesYesNot coveredNot coveredYes- Part D onlyYesYesYesYesYesNot coveredNot coveredYesYesYesYes (excluded)Covered byDMAP

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND NAME(S)(Provided for reference onlyandare not 041Q0239Autologous Cultured ChondrocytesAvelumabAxicabtagene ceptBelantamab mafodotinNulojixBlenrepJ0490BelimumabBenlysta IVBenlysta daBendekaBelrapzoFasenra315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416AUTHORIZATION REQUIREDAdvantage (Plus)MembersOHP MembersNot coveredYesYesDrug notcovered, servicesuse M0239Not coveredYesYesDrug notcovered, servicesuse M0239YesYesYesYesYesYes- Part D onlyYesYes- PharmacyBenefitYesYesYesYesYesYesYesYesYesYes

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameJ9035Bevacizumab for CHEMOTHERAPY* bevacizumab for eye use should use J7999 andno authorization is 632Bevacizumab biosimilar for CHEMOTHERAPYBevacizumab biosimilar for CHEMOTHERAPYBezlotoxumabBimatoprost, intracameral implantBlinatumomabBortezomibBortezomibBrentuximab vedotinBrexanoloneQ2053,C9073*BRAND NAME(S)(Provided for reference onlyandare not all-inclusive)Avastin for CHEMOTHERAPYAdvantage (Plus)MembersOHP MembersYesYesMvasi for CHEMOTHERAPYZirabev for eredunderhospitalizationthat may hospitalizationthat may requirePAYesYesYes- Part D onlyYes- PharmacyBenefitYesYesTecartusJ3590Brexucabtagene llBuprenorphineBeovuSubutex315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416AUTHORIZATION REQUIRED

Injectable and Oncology MedicationsAdministered by ProviderHCPCJ0572J0573J0574J0575Generic prenorphine/NaloxoneBuprenorphine/NaloxoneBRAND NAME(S)(Provided for reference onlyandare not ORIZATION REQUIREDAdvantage (Plus)MembersPart D onlyRetail Pharmacy:No PAMed Dispensedat Clinic:ExcludedOHP MembersRetail Pharmacy No PAMed Dispensedat Clinic HSO- refer toCounty.JCC or CPCCO- noPA requiredJ0570Q9991Buprenorphine ImplantBuprenorphine ER Injection 100mgProbuphineSublocadeNot CoveredNo PA ReqdYesYes** (see MATnote)Q9992Buprenorphine ER Injection 300mgSublocadeNo PA ReqdYes** (see MATnote)J0584J0598Burosumab-twzaC1 esterase inhibitorJ0599C1 esterase inhibitorCrysvitaCinryze IVHaegarda SubQYesYesYes- Part D onlyYesYesYes- tegravir/RilpivirineCalaspargaseCalcitonin salmonJevtanaCabenuvaAsparlasMiacalcin, CalcimarYesYesYesYes- Part D onlyYesYesYesNo PA Reqd315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND NAME(S)AUTHORIZATION REQUIRED(Provided for reference onlyandare not all-inclusive)IlarisDuopaKyprolisCabliviAdvantage (Plus)MembersOHP ilzomibCaplacizumab-yhdpCapsaicin patchCasirivimab and imedvimabQutenzaYesDrug notcovered, servicesuse M0243YesDrug notcovered, servicesuse ayoOxervateYesYesYesYesYesYesYesYesCerliponase alfa (recombinant mabCetuximabCoagulation factor XaCimziaErbituxAndexxaJ0775J9057Collagenase clostridium histolyticumCopanlisibXiaflexAliqopa315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416Yes- Part D onlyYesYesYesHospital/ED Use only (no PA in thesesettings)YesYesYesYes

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND inCrizanlizumabDaunorubicin (liposomal)-cytarabineDaratumumabDaratumumab- hyaluronidase(Provided for reference onlyandare not all-inclusive)Acthar gelAdakveoVyxeosDarzalexDarzalex 7J9999,J3590DarbepoetinDeoxycholic acidDexamethasone Intra-vitreal ImplantDexamethasone, lacrimal ophthalmic insertDexamethasone intra-ocular nDefitelioFirmagonProlia, XgevaUnituxinQ2049Q2050J3590Doxorubicin, liposomal. ImportedDoxorubicin, mabImfinzi315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416AUTHORIZATION REQUIREDAdvantage (Plus)MembersOHP MembersYes- Part D sYesYesYesNo PA s- Part D onlyYesYesYes- PharmacyBenefitYesYes

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND egademaseElosulfase alfa(Provided for reference onlyandare not ponsaFuzeonJ9177J0885Q5106EnfortumabEpoetin alfa (non-ESRD)Epoetin alfa, biosimilar (non-ESRD)Epoetin beta (non-ESRD)EpoprostenolEpoprostenol t, EpogenRetacritNeoRecormon, MirceraFlolanFlolan 2J9179315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416AUTHORIZATION REQUIREDAdvantage (Plus)MembersOHP MembersYesYesYesYesYesYesYesNot coveredYesYesYesYesPart D only, Noauth sYesYesYesYesYesYesYesYesYes

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND NAME(S)AUTHORIZATION REQUIREDS0013,J3490,G2082,G2083Esketamine (Nasal Spray)(Provided for reference onlyandare not nerceptEteplirsenEtonogestrelEverolimus (oral)EvolocumabEnbrelExondys 51NexplanonAfinitor, ZortressRepathaYes- Part D onlyYesNot Covered YesYes- Part D onlyYesYesNo PA ReqdYesYes- PharmacyBenefitJ3490ExenatideByetta, BydureonYes- Part D onlyYes- c carboxymaltoseFerric derisomaltoseFluocinolone implantFluocinolone implantFluocinolone vienYutiqNAYesYesYesYesYesNo PA ReqdYesYesYesYesYesYes (excluded)Covered byDMAP xYesYesYesYes315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416Advantage (Plus)MembersOHP MembersYesYes (excluded)Covered byDMAP

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND NAME(S)AUTHORIZATION bine (brand Infugem only)Gemtuzumab ozogamicinGivosiranGlatiramer Acetate(Provided for reference onlyandare not YesYes- SQ- Med mumab, IVGolodirsenGoserelinGranisetron (SQ-long acting)Growth Hormone (somatrem)Growth Hormone (somatropin)GuselkumabSimponi AriaVyondys s- Part D onlyYes- Part D onlyYes- Part D cyBenefitYes (excluded)Covered byDMAP 315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416Advantage (Plus)MembersOHP MembersYesYesYesYesYes- Part D onlyYesYesYesYesPharmacyBenefitNo PA Reqd

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND NAME(S)J1631Haloperidol(Provided for reference onlyandare not istrelin implantHistrelin implantHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHymovisHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHyaluronan or DerivativeHydroxyprogesterone caproateHydroxyprogesterone caproateSupprelinSupprelin LAVantasEuflexxaGel-OneDurolaneGenVisc 850Hyalgan or SupartzHymovisOrthoviscSynvisc, Visco-3not MakenaMakenaJ7331J7332J7333*J1729J1726315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416AUTHORIZATION REQUIREDAdvantage (Plus)MembersOHP MembersNo PA ReqdYes (excluded)Covered byDMAP Yes- Part D onlyYesYesYes- ST req'dYes- ST req'dNo PA ReqdYes- ST req'dYes- ST req'dYes- ST req'dYes- ST req'dNo PA ReqdYes- ST req'dNo PA ReqdYes- ST req'dYes- ST req'dYes- ST req'dYes- ST req'dYesYesYesYesYesNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredYesYes

Injectable and Oncology MedicationsAdministered by ProviderHCPCGeneric NameBRAND , mmune Globulin lyophilized, IVImmune Globulin, IM(Provided for reference onlyandare not ymeRecarbrioCarimuneGamaStan 75J1555J3490Immune Globulin, IVImmune Globulin, IVImmune Globulin, IVImmune Globulin, IVImmune Globulin, SQImmune Globulin, IVImmune Globulin, IVImmune Globulin, IV,Immune Globulin, IVImmune Globulin/hyaluronidaseImmune Globulin, SQFlebogammaGammagardGammaplexGamunex, GammakedHizentraNonlyophilized (NOS)OctagamPrivigenBivigamHyqviaCuvitru315 SW Fifth Ave, Portland, OR 97204 800-224-4840 TTY 711 careoregon.orgMED-21174165-0416AUTHORIZATION REQUIREDAdvantage (Plus)MembersOHP MembersYesYesYes- Part D onlyYesYesYesYesYesYesYesNo PA ReqdYesYesYesYesYesYesYesYesYesYes- Part D esYes