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GHC SPECIALTY MEDICATIONSLast Update: 6/1/2021***Coverage of gene therapies is not addressed in this document***NEW TO MARKET MEDICATIONSNewly-available medications may be subject to GHC-SCW’s Coverage of New-to-market Drugs policy. If the medicationyou are seeking coverage for is listed below, it is not covered and claims for the drug will be denied in concordance withthe policy. The list is current as of the date of this document. Drugs which have been made available since the date ofthis document will not be covered.HCPCS CodeJ3490J9999J9999J3490J9999Brand NameAmondys 45JemperliZynlontaEmpaveliRybrevantGeneric NamecasimersenDostarlimab-gxlyLoncastuximab tesirine-lpylpegcetacoplanamivantamab-vmjwPHARMACY BENEFIT ONLY MEDICATIONSCoverage of the following medications is restricted to the Pharmacy benefit. Claims submitted on the Medical benefitwill be denied. Please note that these drugs may require Prior Authorization per the Formulary.HCPCS 3490J7639J3590J3357J0593J7682J7686Brand mptaOral prescription drug non chemoOral prescription drug non vasoGeneric NameCertolizumab pegolEtanerceptsatralizumabC1 Esterase InhibitorEmicizumab-kxwhAdalimumabofatumumabOral prescription drug non chemoOral prescription drug non chemoLetermovirDornase cin Inh SolnTreprostinil Inh Soln
GHC SPECIALTY MEDICATIONSLast Update: 6/1/2021SPECIALTY INJECTABLES PRIOR AUTHORIZATION LISTPrior authorization is required for clinic-administered injectable medications. Monthly updates will be added to the PriorAuthorization list. Providers are reminded to review the Prior Authorization list on a regular basis for any updates orchanges which may be added.PLEASE NOTE: Magellan or GHC Prior Authorization?The medications highlighted below in yellow required Prior Authorization from our partner, Magellan. Please click HEREto start the Prior Authorization process for these medications.All other medications on the list below require Prior Authorization from GHC-SCW. Please click HERE to start the PriorAuthorization process for these medications. Please contact Member Services with specific code information todetermine if an item or service requires prior authorization. Member Services Phone: (800) 605-4327.MAGELLAN RX SPECIALTY PHARMACY: When (and only when) GHC is the primary payor, select drugs must besourced through Magellan Rx Specialty Pharmacy. Users will be guided in the Magellan Rx PA portal to set this up. Pleasebe aware that if your practice is accustomed to “buy-and-bill,” those claims for reimbursement will be denied.HCPCSBrand NameGeneric NameJ9264AbraxanePaclitaxelJ3262J0800ActemraActhar HPTocilizumabCorticotropinJ2504AdagenPegademase ab datoryDistributionthroughMagellan nlisibPalonosetronYJ0256J0881AralastAranespAlpha-1 proteinase mumabIVIG (Human)-slraJ9118AsparlasCalaspargase pegol-mknlJ9035AvastinBevacizumab Only for Cancer DxQ5121A9590AvsolaAzedraInfliximab axxqIobenguane I-131J9023BavencioAvelumabY
GHC SPECIALTY MEDICATIONSHCPCSLast Update: 6/1/2021Brand NameGeneric NameMandatoryDistributionthroughMagellan rolucizumab-dbllYJ0597BerinertC1 InhibitorJ9229BesponsaInotuxumab ozogamicinJ1556J9037BivigamBlenrepIntravenous Immune Carimune NFCerliponase alfaIntravenous Immune izumabJ0598J3490CinryzeCoselaC1 InhibitorTrilaciclibJ3590CutaquigImmune globulin SC (human)-hippJ1555CuvitruSubcutaneous Immune ratumumabJ9144Darzalex FasproDefitelioDaratumumab and aluronan or sTaliglucerase alfaLeuprolide acetate (for iEnhertuElotuzumabFam-trastuzumab Hyaluronan or derivativeY
GHC SPECIALTY MEDICATIONSHCPCSLast Update: 6/1/2021Brand NameGeneric NameJ3590EvkeezaEvinacumab-dgnbJ1428J3111Exondys e heme (non-esrd)Leuprolide AcetateferumoxytolQ0139Feraheme 5J1572FlebogammaDegarelixIntravenous Immune GlobulinMandatoryDistributionthroughMagellan Levoleucovorin CalciumEmapalumab-lzsgJ1569Gammagard LiquidIntravenous Immune GlobulinYJ1566J1561Gammagard S/DGammakedImmune GlobulinIntravenous Immune GlobulinYJ1557GammaplexIntravenous Immune GlobulinJ1561Gamunex-CIntravenous Immune GlobulinYYJ0132J9301Ganirelix luronan or derivativeYJ7328Gelsyn-3Hyaluronan or derivativeJ7320Genvisc 850GivlaariHyaluronan or derivativeJ0223J0257J9179YHalavenGivosiranAralast, Aralast NPEribulinJ9355J9356HerceptinHerceptin HylectaTrastuzumabTrastuzumab and zumab-pkrbSubcutaneous Immune GlobulinYYJ7321J7322HyalganHymovisHyaluronan or derivativeHyaluronan or derivativeYJ1575HyQviaSubcutaneous Immune GlobulinGlassiaY
GHC SPECIALTY MEDICATIONSHCPCSLast Update: 6/1/2021Brand lumyaGeneric xTalimogene ybJ9198J1439InfugemInjectaferIntravenous ImmuneGlobulinIprivaskGemcitabineFerric 315J9207J9281MandatoryDistributionthroughMagellan RxSpecialtyPharmacyIntravenous Immune GlobulinDesirudinJelmytoIxabepiloneMitomycin for pyelocaliceal laKalbitorAdo-trastuzumab 2840KanumaSebelipase bizumabJ0221J9313LumizymeLumoxitiAlglucosidase alfaMoxetumomab pasudotox-tdfkJ9217Lupron DepotJ1950Lupron DepotJ1950Lupron Depot de acetate (for depotsuspension)Leuprolide acetate (for depotsuspension)Leuprolide acetate (for depotsuspension)lutetium Lu 177 dotatatePegaptanibMargetuximab-cmkbYYYYY
GHC SPECIALTY MEDICATIONSHCPCSLast Update: 6/1/2021Brand NameGeneric NameMandatoryDistributionthroughMagellan RxSpecialtyPharmacyYJ9371MarqiboVincristine LiposomalJ3397MepseviiVestronidase alfa-vjvkJ2788J9349MicrhogamMonjuviRho(D) immune globulinTafasitamab-cxixJ1437Monoferricferric derisomaltoseJ7327MonoviscHyaluronan or derivativeJ9203J0587MylotargMyoblocGemtuzumuab amOctreotide AcetateOgivriIntravenous Immune Irinotecan yaluronan or derivativeLumasiranJ9177PadcevEnfortumab vedotin-ejfvJ1599J9304PanzygaPemfexyIntravenous Immune GlobulinPemetrexedJ9999Pepaxtomelphalan zumabPertuzumab, trastuzumab andhyaluronidasePolatuzumab vedotin-piiqYYYYYY
GHC SPECIALTY MEDICATIONSHCPCSLast Update: 6/1/2021Brand NameGeneric NameMandatoryDistributionthroughMagellan IdarucizumabJ1459PrivigenZiconotideIntravenous Immune GlobulinJ0885Procrit/EpogenEpoetin se an HycelaRituximab and hyaluronidase humanJ0596Q5119RuconestRuxienceC1 Esterase Inhibitor [recombinant]Rituximab-pvvrYJ2353Sandostatin 02ScenesseSimponi ARIAAfamelanotideGolimumabJ3490Sodium Hyaluronate1% hyaluronan or extranomer-Sodium pravatoNusinersenEsketamineJ3358J7321Stelara IVSupartzUstekinumabHyaluronan or derivativeJ9226Supprelin LAHistrelin Implant (50 mg)YYYYYY
GHC SPECIALTY MEDICATIONSHCPCSLast Update: 6/1/2021Brand NameGeneric NameMandatoryDistributionthroughMagellan RxSpecialtyPharmacyJ1627SustolGranisetron ynriboSynviscOmacetaxineHyaluronan or derivativeYJ7325Synvisc-OneHyaluronan or derivativeYJ7331SynojoyntHyaluronan or delvyTriptorelinHyaluronan or derivativeSacituzumab ibixHistrelin 321Visco-3Elosulfase AlfaHyaluronan or yeptiVelagluceraseJ1429Vyondys 53J9153J1558YTriptorelin PamoateHyaluronan or enDaunorubicin and cytarabineImmune globulin SC gevaDenosumabY
GHC SPECIALTY MEDICATIONSHCPCSLast Update: 6/1/2021Brand NameGeneric NameJ0775XiaflexJ2357XolairCollagenase Clostridium imumabTrabectedinJ7314YutiqFluocinolone iraZepzelcaAlpha1-Proteinase Inhibitor MandatoryDistributionthroughMagellan RxSpecialtyPharmacyYY
Jun 01, 2021 · HCPCS Code Brand Name Generic Name J3490 Amondys 45 casimersen J9999 Jemperli Dostarlimab-gxly J9999 Zynlonta Loncastuximab tesirine-lpyl J3490 Empaveli pegcetacoplan . J9047 Kyprolis Carfilzomib Y J9285 Lartruvo Olaratumab J0202 Lemtrada Alemtuzumab J91
