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Oncology Drug Program - Additional Codes Require Preauthorization Effective August 15, 2021

Switch to:

Oncology Drug Program - Additional Codes Require Preauthorization Effective August 15, 2021

06/10/2021

Date: 2021/06/10

Starting Aug. 15, 2021, additional oncology-related chemotherapeutic drugs and supportive agents when delivered in the physician’s office, outpatient hospital, or other ambulatory setting will require preauthorization. See EmblemHealth’s Frequently Asked Questions: EmblemHealth Oncology Drug Management to determine where to submit the preauthorization request.

HCPCS	Brand Name	Generic Name	Medication Type
C9065	ROMIDEPSIN	ROMIDEPSIN INJECTION	Cancer Treatment
J9037	BLENREP	BELANTAMAB MAFODOTIN-BLMF INJECTION	Cancer Treatment
J9349	MONJUVI	TAFASITAMAB-CXIX	Cancer Treatment
J0594	BUSULFEX	INJECTION BUSULFAN 1 MG	Cancer Treatment
J0640	LEUCOVORIN	INJECTION LEUCOVORIN CALCIUM PER 50 MG	Supportive Medication
J1453	EMEND	INJECTION FOSAPREPITANT 1 MG	Supportive Medication
J1627	SUSTOL	GRANISETRON HCL EXTENDED RELEASE INJECTION	Supportive Medication
J2430	AREDIA	INJECTION PAMIDRONATE DISODIUM PER 30 MG	Bone Mets
J9000	ADRIAMYCIN	DOXORUBICIN HCL INJECTION	Cancer Treatment
J9017	TRISENOX	INJECTION ARSENIC TRIOXIDE 1 MG	Cancer Treatment
J9019	ERWINAZE	ERWINAZE INJECTION	Cancer Treatment
J9030	TICE	BCG LIVE INTRAVESICAL VAC	Cancer Treatment
J9032	BELEODAQ	BELINOSTAT	Cancer Treatment
J9040	BLENOXANE	INJECTION BLEOMYCIN SULFATE 15 UNITS	Cancer Treatment
J9045	PARAPLATIN	INJECTION CARBOPLATIN 50 MG	Cancer Treatment
J9050	BICNU	INJECTION CARMUSTINE 100 MG	Cancer Treatment
J9060	PLATINOL	INJECTION CISPLATIN POWDER OR SOLUTION 10 MG	Cancer Treatment
J9065	LEUSTATIN	INJECTION CLADRIBINE PER 1 MG	Cancer Treatment
J9070	CYTOXAN	CYCLOPHOSPHAMIDE 100 MG	Cancer Treatment
J9100	CYTOSAR-U	INJECTION CYTARABINE 100 MG	Cancer Treatment
J9120	COSMEGEN	INJECTION DACTINOMYCIN 0.5 MG	Cancer Treatment
J9130	DTIC-DOME	DACARBAZINE 100 MG	Cancer Treatment
J9144	DARZALEX FASPRO	DARATUMUMAB/HYALURONIDASE-FIHJ	Cancer Treatment
J9150	DAUNORUBICIN	INJECTION DAUNORUBICIN 10 MG	Cancer Treatment
J9155	FIRMAGON	INJECTION DEGARELIX 1 MG	Cancer Treatment
J9171	TAXOTERE	INJECTION DOCETAXEL 1 MG	Cancer Treatment
J9178	ELLENCE	EPIRUBICIN	Cancer Treatment
J9181	TOPOSAR	ETOPOSIDE INJECTION	Cancer Treatment
J9185	FLUDARA	INJECTION FLUDARABINE PHOSPHATE 50 MG	Cancer Treatment
J9190	ADRUCIL	INJECTION FLUOROURACIL 500 MG	Cancer Treatment
J9200	FUDR	INJECTION FLOXURIDINE 500 MG	Cancer Treatment
J9201	GEMZAR	INJECTION GEMCITABINE HCL 200 MG	Cancer Treatment
J9202	ZOLADEX	GOSERELIN ACETATE IMPLANT PER 3.6 MG	Cancer Treatment
J9206	CAMPTOSAR	INJECTION IRINOTECAN 20 MG	Cancer Treatment
J9208	IFEX	INJECTION IFOSFAMIDE 1 G	Cancer Treatment
J9209	MESNEX	INJECTION MESNA 200 MG	Cancer Treatment
J9211	IDAMYCIN	INJECTION IDARUBICIN HCL 5 MG	Cancer Treatment
J9223	ZEPZELCA	LURBINECTEDIN	Cancer Treatment
J9245	ALKERAN	INJECTION MELINJECTION MELPHALAN HCL 50 MG	Cancer Treatment
J9261	ARRANON	INJECTION NELARABINE 50 MG	Cancer Treatment
J9266	ONCASPAR	INJECTION PEGASPARGASE PER SINGLE DOSE VIAL	Cancer Treatment
J9267	TAXOL	PACLITAXEL INJECTION	Cancer Treatment
J9268	NIPENT	INJECTION PENTOSTATIN 10 MG	Cancer Treatment
J9280	MUTAMYCIN	MITOMYCIN 5 MG	Cancer Treatment
J9281	JELMYTO	MITOMYCIN PYELOCALYCEAL SOLUTION	Cancer Treatment
J9293	NOVANTRONE	INJECTION MITOXANTRONE HCL PER 5 MG	Cancer Treatment
J9316	PHESGO	PERTUZUMAB/TRASTUZUMAB/HYALURONIDASE-ZZXF INJECTION	Cancer Treatment
J9317	TRODELVY	SACITUZUMAB GOVITECAN-HZIY	Cancer Treatment
J9320	ZANOSAR	INJECTION STREPTOZOCIN 1 G	Cancer Treatment
J9351	HYCAMTIN	INJECTION TOPOTECAN 0.1 MG	Cancer Treatment
J9357	VALSTAR	INJECTION VALRUBICIN INTRAVESICAL 200 MG	Cancer Treatment
J9360	VELBAN	INJECTION VINBLASTINE SULFATE 1 MG	Cancer Treatment
J9370	ONCOVIN	VINCRISTINE SULFATE 1 MG	Cancer Treatment
J9390	NAVELBINE	INJECTION VINORELBINE TARTRATE 10 MG	Cancer Treatment
J9395	FASLODEX	INJECTION FULVESTRANT 25 MG	Cancer Treatment
J9600	PHOTOFRIN	INJECTION PORFIMER SODIUM 75 MG	Cancer Treatment
Q2017	VUMON	TENIPOSIDE 50 MG	Cancer Treatment

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