EmblemHealth has changed its prior authorization utilization management (UM) services provider for medications billed through the Medical benefit. Magellan was our previous vendor for these services.
Effective Jan. 1, 2019, EmblemHealth’s Pharmacy Utilization Management team will review all requests for the medications listed on the following pages.
What do I need to do?
Send all utilization management requests for these medications to EmblemHealth’s Pharmacy Department, starting Jan. 1, 2019. You can request authorizations by:
- Fax: 877-243-4812
- Phone: 888-447-0295
- Prompt PA: emblem.promptpa.com
Clearly define your preference regarding method of medication delivery on the request form. Your options are:
- Buy and Bill – if you currently have the medication or purchase separately and wish to bill EmblemHealth; or
- Drug Delivery Required – EmblemHealth’s Specialty Pharmacy, Accredo, will ship the medication to your office.
- Also, clearly define the dose and frequency of administration of the medication.
If you have questions, call us at 888-447-0295. Our hours are 8 a.m. to 6 p.m., Monday to Friday. A representative will be happy to help.
| Brand Name | Generic Name | HCPCS |
|---|---|---|
| Abraxane | paclitaxel protein-bound | J9264 |
| Actemra | tocilizumab | J3262 |
| Acthar HP | corticotropin | J0800 |
| Akynzeo | fosnetupitant and palonosetron | J1454 |
| Aldurazyme | laronidase | J1931 |
| Alimta | pemetrexed disodium | J9305 |
| Aliqopa | Copanlisib | J9057 |
| Aloxi | palonosetron hydrochloride | J2469 |
| Aranesp | darbepoetin alfa | J0881 |
| Avastin | bevacizumab | J9035 |
| Azedra | Iobenguane I-131 | C9407, C9408 |
| Bavencio | Avelumab | J9023 |
| Benlysta | belimumab | J0490 |
| Berinert | C1 esterase inhibitor (Human) | J0597 |
| Bivigam | Intravenous Immune Globulin | J1556 |
| Blincyto | Blinatumomab | J9039 |
| Botox | onabotulinumtoxinA ; | J0585 |
| Brineura | Cerliponase alfa | J0567 |
| Carimune | immune globulin intravenous | J1566 |
| Cerezyme | imiglucerase | J1786 |
| Cimzia | certolizumab pegol | J0717 |
| Cinryze | C1 esterase inhibitor (Human) | J0598 |
| Crysvita | burosumab-twza | J0584 |
| Cyramza | ramucirumab | J9308 |
| Durolane | hyaluronic acid | J7318 |
| Dysport | abobotulinumtoxinA | J0586 |
| Elaprase | idursulfase | J1743 |
| Elelyso | taliglucerase alfa | J3060 |
| Entyvio | vedolizumab | J3380 |
| Epogen/Procrit | epoetin alfa | J0885 |
| Erbitux | cetuximab | J9055 |
| Euflexxa | hyaluronate sodium | J7323 |
| Eylea | aflibercept | J0178 |
| Fabrazyme | agalsidase beta | J0180 |
| Fasenra | benralizumab | J0517 |
| Firazyr | icatibant | J1744 |
| Flebogamma | immune globulin intravenous | J1572 |
| Fulphila | pegfilgrastim-jmdb | Q5108 |
| Fusilev | levoleucovorin calcium | J0641 |
| Gammagard | immune globulin intravenous | J1569 |
| Gammaplex | Intravenous Immune Globulin | J1557 |
| Gamunex | immune globulin intravenous | J1561 |
| Gel-One | hyaluronate sodium | J7326 |
| Halaven | eribulin | J9179 |
| Herceptin | trastuzumab | J9355 |
| Hizentra | subcutaneous immune globulin | J1559 |
| Hyalgan | hyaluronate sodium | J7321 |
| Hymovis | hyaluronic acid | J7322 |
| Hyqvia | subcutaneous immune globulin | J1575 |
| Ilumya | tildrakizumab-asmn | J3245 |
| Imfinzi | durvalumab | J9173 |
| Inflectra | infliximab-dyyb | Q5102 |
| Jevtana | cabazitaxel | J9043 |
| Kadcyla | ado-trastuzumab emtansine | J9354 |
| Kalbitor | ecallantide | J1290 |
| Keytruda | pembrolizumab | J9271 |
| Krystexxa | pegloticase | J2507 |
| Kymriah | tisagenlecleucel | Q2042 |
| Kyprolis | carfilzomib | J9047 |
| Lartruvo | olaratumab | J9371 |
| Lemtrada | alemtuzumab | J0202 |
| Leukine | sargramostim | J2820 |
| Lucentis | ranibizumab | J2778 |
| Lumizyme | alglucosidase alfa | J0221 |
| Lutathera | lutetium LU 177 dotatate | A9513 |
| Luxturna | voretigene neparvovec | J3398 |
| Marqibo | vincristine sulfate liposomal | J9371 |
| Mepsevii | vestronidase alfa-vjbk | J3397 |
| Monovisc | hyaluronic acid | J7327 |
| Mvasi | bevacizumab-awwb | Q5107 |
| Mylotarg | gemtuzumab ozogamicin | J9203 |
| Myobloc | rimabotulinumtoxinB | J0587 |
| Naglazyme | galsulfase | J1458 |
| Neulasta | pegfilgrastim | J2505 |
| Neupogen | filgrastim | J1442 |
| Nivestym | filgrastim-aafi | Q5510 |
| Nplate | romiplostim | J2796 |
| Nucala | mepolizumab | J2182 |
| Ocrevus | ocrelizumab | J2350 |
| Octagam | immune globulin intravenous | J1568 |
| Onpattro | patisiran | C9036 |
| Opdivo | nivolumab | J9299 |
| Orencia | abatacept | J0129 |
| Orthovisc | hyaluronic acid | J7324 |
| Poteligeo | mogamulizumab-kpkc | C9038 |
| Perjeta | pertuzumab | J9306 |
| Privigen | immune globulin intravenous | J1459 |
| Prolia | denosumab | J0897 |
| Provenge | sipuleucel-t | Q2043 |
| Radicava | Edaravone | J1301 |
| Reclast | zoledronic acid | J3489 |
| Relizorb | immobilized lipase cartridge | B4105 |
| Remicade | infliximab | J1745 |
| Renflexis | infliximab-abda | Q5104 |
| Rituxan | rituximab | J9310 |
| Ruconest | C1 esterase inhibitor (recombinant) | J0596 |
| Sandostatin | octreotide acetate | J2353 |
| Signifor LAR | Pasireotide | J2502 |
| Simponi aria | golimumab | J1602 |
| Soliris | eculizumab | J1300 |
| Spinraza | Nusinersen | J2326 |
| Stelara | ustekinumab | J3357 |
| Supartz FX | hyaluronic acid | J7321 |
| Synvisc | hylan polymers a and b | J7325 |
| Synvisc-One | hylan polymers a and b | J7325 |
| Trivisc | hyaluronate sodium | J7329 |
| Trogarzo | Ibalizumab-uiyk | J1746 |
| Tysabri | natalizumab | J2323 |
| Udenyca | pegfilgrastim-cbqv | Q5111 |
| Vantas | histrelin implant | J9225 |
| Varubi | rolapitant | J2797 |
| Vectibix | panitumumab | J9303 |
| Velcade | bortezomib | J9041 |
| Vidaza | Azacitidine | J9025 |
| Vpriv | velaglucerase alfa | J3385 |
| Vyxeos | daunorubicin and cytarabine | J9153 |
| Xeomin | incobotulinumtoxinA | J0588 |
| Xgeva | denosumab | J0897 |
| Xolair | omalizumab | J2357 |
| Yervoy | ipilimumab | J9228 |
| Yescarta | axicabtagene ciloleucel | Q2041 |
| Zilretta | triamcinolone acetonide extended release | J3304 |
| Zometa | zoledronic acid | J3489 |
