Prior Authorization for Some Medications Changing in 2019

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:

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