Prior Authorization Update for Evolent

CANCER TREATMENT

  A9513

LUTETIUM LU 177 DOTATATE THERAPEUTIC

1 MCI

 C9163

INJECTION TALQUETAMAB-TGVS

0.25 MG

 C9165

INJECTION ELRANATAMAB-BCMM

1 MG

 J0202

INJECTION ALEMTUZUMAB

1 MG

J0594

INJECTION BUSULFAN

1 MG

J0642

INJECTION, LEVOLEUCOVORIN (KHAPZORY)

0.5 mg

J0791

INJECTION CRIZANLIZUMAB-TMCA

5 MG

J1246

INJECTION DINUTUXIMAB

0.1 MG

J1950

INJ LEUPROLIDE ACETATE PER

3.75 MG

J1952

LEUPROLIDE INJECTABLE CAMCEVI,

1 MG

J1954

INJECTION LA FOR DEPOT SUSPENSION

7.5 MG

J2860

INJECTION SILTUXIMAB

10 MG

J3240

INJ THYROTROPIN PROV 1.1 VIAL

.9 MG

J3315

INJ TRIPTORELIN PAMOATE

3.75 MG

J3316

INJECTION TRIPTORELIN EXTENDED-RELEASE

3.75 MG

J7504

LYMPHOCYTE IMMUNE/ANTITHYMOCYTE GLOBULIN

5ML EA

J8510

BUSULFAN, ORAL

2 MG

J8565

GEFITINIB ORAL

250 mg

J8600

MELPHALAN ORAL

2 MG

J8705

TOPOTECAN, ORAL

0.25 mg

J8999

PRESCRIPTION DRUG-ORAL-CHEMOTHERAPEUTIC-NOS

J9015

ALDESLEUKIN INJECTION

J9017

INJECTION ARSENIC TRIOXIDE

1 MG

J9019

ERWINAZE INJECTION

J9021

INJECT ASPARAGINASE RECOMBINANT (RYLAZE)

0.1 MG

J9022

INJECTION ATEZOLIZUMAB

10 MG

J9023

INJECTION AVELUMAB

10 MG

J9027

INJECTION CLOFARABINE

1 MG

J9029

IVES INSTAL NADOFARAGN FIRADENOVC-VNCG PER THR D

J9030

BCG LIVE INTRAVESICAL INSTILLATION

1 MG

J9032

INJECTION BELINOSTAT

10 MG

J9034

INJ. BENDEKA

1 MG

J9035

INJECTION BEVACIZUMAB

10 MG

J9037

INJECTION, BELANTAMAB MAFODOTIN-BLMF

0.5 mg

J9039

INJECTION BLINATUMOMAB

1 MCG

J9042

BRENTUXIMAB VEDOTIN INJ

J9043

CABAZITAXEL INJECTION

J9047

INJECTION, CARFILZOMIB,

1 MG

J9050

INJECTION CARMUSTINE

100 MG

J9055

INJECTION CETUXIMAB

10 MG

J9056

INJECTION BENDAMUSTINE HCL VIVIMUSTA

1 MG

J9057

INJECTION, COPANLISIB

1 mg

J9061

INJECTION, AMIVANTAMAB-VMJW

2 MG

J9063

INJECTION MIRVETUXIMAB SORAVTANSINE-GYNX

1 MG

J9064

INJECTION, CABAZITAXEL (SANDOZ), NOT THERAPEUTICALLY EQUIVALENT TO J9043

1 mg

J9118

INJECTION CALASPARGASE PEGOL-MKNL

10 UNITS

J9119

INJECTION CEMIPLIMAB-RWLC

1 MG

J9120

INJECTION DACTINOMYCIN

0.5 MG

J9144

INJECTION DARATUMUMAB 10 MG AND HYALURONIDASE FIHJ

J9145

INJECTION DARATUMUMAB

10 MG

J9155

DEGARELIX INJECTION

J9172

INJECTION DOCETAXEL DOCIVYX

1 MG

J9173

INJECTION DURVALUMAB

10 MG

J9176

INJECTION ELOTUZUMAB

1MG

J9177

INJECTION ENFORTUMAB VEDOTIN-EJFV

0.25 MG

J9178

INJECTION, EPIRUBICIN HCI

2 MG

J9179

ERIBULIN MESYLATE INJECTION

J9196

INJ GEMCITABINE HCI NOT THR EQUIV J9201

200 MG

J9198

INJ GEMCITABINE HYDROCHLORIDE INFUGEM

100 MG

J9200

INJECTION FLOXURIDINE

500 MG

J9202

GOSERELIN ACETATE IMPLANT PER

3.6 MG

J9203

INJ GEMTUZUMAB OZOGAMICIN

0.1 MG

J9204

INJECTION MOGAMULIZUMAB-KPKC

1 MG

J9207

IXABEPILONE INJECTION

J9210

INJECTION EMAPALUMAB-LZSG

1 MG

J9214

INTERFERON ALFA-2B INJ

J9223

INJECTION LURBINECTEDIN

0.1 MG

J9227

INJECTION ISATUXIMAB-IRFC

10 MG

J9228

IPILIMUMAB INJECTION

J9229

INJECTION INOTUZUMAB OZOGAMICIN

0.1 MG

J9230

MECHLORETHAMINE HCL INJ

J9246

INJECTION MELPHALAN EVOMELA

1 MG

J9247

INJECTION, MELPHALAN FLUFENAMIDE

1 mg

J9258

INJ PTX PRO-BND PA TEVA NOT EQUIV TO J9264

1 MG

J9259

INJ PTX PRO-BND PA AMER REG NOT EQ J9264

1 MG

J9261

INJECTION NELARABINE

50 MG

J9262

INJECTION, OMACETAXINE MEPESUCCINATE

0.01 mg

J9264

INJECTION PACLITAXEL PROTEIN-BOUND PARTICLES

1 MG

J9268

INJECTION PENTOSTATIN

10 MG

J9269

INJECTION TAGRAXOFUSP-ERZS

10 MCG

J9271

INJECTION PEMBROLIZUMAB

1 MG

J9272

INJECTION, DOSTARLIMAB-GXLY

10 MG

J9273

INJECTION, TISOTUMAB VEDOTIN-TFTV

1 MG

J9274

INJECTION TEBENTAFUSP-TEBN

1 MCG

J9281

MITOMYCIN PYELOCALYCEAL INSTILLATION

1 MG

J9285

INJECTION, OLARATUMAB

10 mg

J9286

INJECTION GLOFITAMAB-GXBM

2.5 MG

J9295

INJECTION NECITUMUMAB

1 MG

J9298

INJECTION NIVOLUMAB AND RELATLIMAB-RMBW

3 MG/1 MG

J9299

INJECTION NIVOLUMAB

1 MG

J9301

OBINUTUZUMAB INJ

J9302

OFATUMUMAB INJECTION

J9303

PANITUMUMAB INJECTION

J9305

INJECTION PEMETREXED NOS

10 MG

J9307

PRALATREXATE INJECTION

J9308

INJECTION RAMUCIRUMAB

5 MG

J9309

INJECTION POLATUZUMAB VEDOTIN-PIIQ

1 MG

J9311

INJECTION RITUXIMAB 10 MG AND HYALURONIDASE

J9312

INJECTION RITUXIMAB

10 MG

J9313

INJECTION, MOXETUMOMAB PASUDOTOX-TDFK

0.01 mg

J9316

INJ PERTUZUMAB TRASTUZUMAB AND HYAL ZZXF PER

10 MG

J9317

INJECTION SACITUZUMAB GOVITECAN HZIY

2.5 MG

J9318

INJECTION ROMIDEPSIN NONLYOPHILIZED

0.1 MG

J9319

INJECTION ROMIDEPSIN LYOPHILIZED

0.1 MG

J9320

INJECTION, STREPTOZOCIN

1 g

J9321

INJECTION EPCORITAMAB-BYSP

0.16 MG

J9325

INJ TALIMOGENE LAHERPAREPVEC

J9330

TEMSIROLIMUS INJECTION

J9331

INJECTION SIROLIMUS PROTEIN-BOUND PARTICLES

1 MG

J9340

INJECTION THIOTEPA

15 MG

J9345

INJECTION, RETIFANLIMAB-DLWR

1 mg

J9347

INJECTION TREMELIMUMAB-ACTL

1 MG

J9348

INJECTION NAXITAMAB-GQGK

1 MG

J9349

INJECTION TAFASITAMAB-CXIX

2 MG

J9350

INJECTION MOSUNETUZUMAB-AXGB

1 MG

J9352

INJECTION TRABECTEDIN

0.1MG

J9353

INJECTION MARGETUXIMAB-CMKB

5 MG

J9354

INJ, ADO-TRASTUZUMAB EMT

1 MG

J9355

INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR

10 MG

J9356

INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK

J9357

INJECTION, VALRUBICIN, INTRAVESICAL

200 mg

J9358

INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI

1 MG

J9359

INJECTION, LONCASTUXIMAB TESIRINE-LPYL

0.075 MG

J9371

INJ, VINCRISTINE SUL LIP

1 MG

J9380

INJECTION TECLISTAMAB-CQYV

0.5 MG

J9393

INJECT FULVESTRANT NOT THR EQUIV TO J9395

25 MG

J9394

INJ FUL FRESENIUS KABI NOT TX EQV TO J9395

25 MG

J9400

INJ, ZIV-AFLIBERCEPT

1 MG

J9600

PORFIMER SODIUM INJECTION

J9999

NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUGS

Q2017

INJECTION, TENIPOSIDE

50 mg

Q2043

SIPLEUCEL-T AUTO CD54+

Q5107

INJECTION BEVACIZUMAB-AWWB BIOSIMILAR

10 MG

Q5112

INJECTION TRASTUZUMAB-DTTB BIOSIMILAR

10 MG

Q5113

INJECTION TRASTUZUMAB-PKRB BIOSIMILAR

10 MG

Q5114

INJECTION TRASTUZUMAB-DKST BIOSIMILAR

10 MG

Q5115

INJECTION RITUXIMAB-ABBS BIOSIMILAR

10 MG

Q5117

INJECTION TRASTUZUMAB-ANNS BIOSIMILAR

10 MG

Q5118

INJECTION BEVACIZUMAB-BVZR BIOSIMILAR

10 MG

Q5119

INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE

10 MG

Q5123

INJECTION RITUXIMAB-ARRX BIOSIMILAR

10 MG

Q5126

INJ BEVACIZUMAB-MALY BIOSIMILAR (ALYMSYS)

10 MG

Q5129

INJECTION BEVACIZUMAB-ADCD BIOSIMILAR

10 MG

ESA

J0881

INJECTION DARBEPOETIN ALFA NON-ESRD USE

1 MCG

J0885

INJECTION EPOETIN ALFA FOR NON-ESRD USE

1000 U

J0888

EPOETIN BETA NON ESRD

J0896

INJECTION LUSPATERCEPT-AAMT

0.25 MG

Q5106

INJECTION EPOETIN ALFA-EPBX BIOSIMILAR

1000 U

IRON

J1439

INJ FERRIC CARBOXYMALTOS

1MG

Q0138

FERUMOXYTOL, NON-ESRD

MYELOID GROWTH FACTOR

J1447

INJECTION TBO-FILGRASTIM

1 MCG

J1449

INJECTION EFLAPEGRASTIM-XNST

0.1 MG

J2506

INJECT PEGFILGRASTIM EXCLUDES BIOSIMILAR

0.5 MG

Q5101

INJECTION, ZARXIO

Q5108

INJECTION PEGFILGRASTIM-JMDB BIOSIMILAR

0.5 MG

Q5110

INJ FILGRASTIM-AAFI BIOSIMILR

1 MCG

Q5111

INJECTION PEGFILGRASTIM-CBQV BIOSIMILAR

0.5 MG

Q5120

INJECTION PEGFILGRASTIM-BMEZ BIOSIMILAR

0.5 MG

Q5125

INJECTION FILGRASTIM-AYOW BIOSIMILAR

1 MCG

Q5127

INJECTION PEG-FPGK STIMUFEND BIOSIMILAR

0.5 MG

Q5130

INJECTION PEG-PBBK FYLNETRA BIOSIMILAR

0.5 MG

SUPPORTIVE MEDICATION

C9047

INJECTION, CAPLACIZUMAB-YHDP

1 MG

C9293

INJECTION, GLUCARPIDASE

10 u

J0207

INJECTION, AMIFOSTINE

500 mg

J1302

INJECTION SUTIMLIMAB-JOME

10 MG

J1437

INJECTION FERRIC DERISOMALTOSE

10 MG

J1448

INJECTION TRILACICLIB

1 MG

J1454

INJ FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG

J1459

INJ IVIG PRIVIGEN

500 MG

J1460

INJ GAMMA GLOBULIN IM

1 CC

J1554

INJECTION IMMUNE GLOBULIN ASCENIV

500 MG

J1555

INJECTION IMMUNE GLOBULIN

100 MG

J1556

INJ, IMM GLOB BIVIGAM

500MG

J1557

GAMMAPLEX INJECTION

J1558

INJECTION IMMUNE GLOBULIN XEMBIFY

100 MG

J1560

INJ GAMMA GLOBULIN IM OVER

10 CC

J1561

GAMUNEX-C/GAMMAKED

J1566

IMMUNE GLOBULIN, POWDER

J1568

OCTAGAM INJECTION

J1569

GAMMAGARD LIQUID INJECTION

J1572

FLEBOGAMMA INJECTION

J1575

INJ IG/HYALURONIDASE

100 MG IG

J1576

INJECTION IMMUNE GLOBULIN IV NON-LYOPH

500 MG

J1599

IVIG NON-LYOPHILIZED, NOS

J1930

INJECTION LANREOTIDE

1 MG

J1932

INJECTION LANREOTIDE

1 MG

J2353

INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION

1 MG

J2354

INJ OCTREOTIDE NON-DEPOT FORM SUBQ/IV INJ

25 MCG

J2562

PLERIXAFOR INJECTION

J2783

INJECTION, RASBURICASE

0.5 MG

J2796

ROMIPLOSTIM INJECTION

J3490

UNCLASSIFIED DRUGS

J3590

UNCLASSIFIED BIOLOGICS

J8499

PRESCRIPTION DRUG-ORAL-NON-CHEMOTHERAPEUTIC-NOS