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HIP HMO Preferred Gold Plan

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. 

 

HCPCSBrand NameGeneric NameMedication Type
C9065ROMIDEPSINROMIDEPSIN INJECTIONCancer Treatment
J9037BLENREPBELANTAMAB MAFODOTIN-BLMF INJECTIONCancer Treatment
J9349MONJUVITAFASITAMAB-CXIXCancer Treatment
J0594BUSULFEXINJECTION BUSULFAN 1 MGCancer Treatment
J0640LEUCOVORININJECTION LEUCOVORIN CALCIUM PER 50 MGSupportive Medication
J1453EMENDINJECTION FOSAPREPITANT 1 MGSupportive Medication
J1627SUSTOLGRANISETRON HCL EXTENDED RELEASE INJECTIONSupportive Medication
J2430AREDIAINJECTION PAMIDRONATE DISODIUM PER 30 MGBone Mets
J9000ADRIAMYCINDOXORUBICIN HCL INJECTIONCancer Treatment
J9017TRISENOXINJECTION ARSENIC TRIOXIDE 1 MGCancer Treatment
J9019ERWINAZEERWINAZE INJECTIONCancer Treatment
J9030TICEBCG LIVE INTRAVESICAL VACCancer Treatment
J9032BELEODAQBELINOSTATCancer Treatment
J9040BLENOXANEINJECTION BLEOMYCIN SULFATE 15 UNITSCancer Treatment
J9045PARAPLATININJECTION CARBOPLATIN 50 MGCancer Treatment
J9050BICNUINJECTION CARMUSTINE 100 MGCancer Treatment
J9060PLATINOLINJECTION CISPLATIN POWDER OR SOLUTION 10 MGCancer Treatment
J9065LEUSTATININJECTION CLADRIBINE PER 1 MGCancer Treatment
J9070CYTOXANCYCLOPHOSPHAMIDE 100 MGCancer Treatment
J9100CYTOSAR-UINJECTION CYTARABINE 100 MGCancer Treatment
J9120COSMEGENINJECTION DACTINOMYCIN 0.5 MGCancer Treatment
J9130DTIC-DOMEDACARBAZINE 100 MGCancer Treatment
J9144DARZALEX FASPRODARATUMUMAB/HYALURONIDASE-FIHJCancer Treatment
J9150DAUNORUBICININJECTION DAUNORUBICIN 10 MGCancer Treatment
J9155FIRMAGONINJECTION DEGARELIX 1 MGCancer Treatment
J9171TAXOTEREINJECTION DOCETAXEL 1 MGCancer Treatment
J9178ELLENCEEPIRUBICINCancer Treatment
J9181TOPOSARETOPOSIDE INJECTIONCancer Treatment
J9185FLUDARAINJECTION FLUDARABINE PHOSPHATE 50 MGCancer Treatment
J9190ADRUCILINJECTION FLUOROURACIL 500 MGCancer Treatment
J9200FUDRINJECTION FLOXURIDINE 500 MGCancer Treatment
J9201GEMZARINJECTION GEMCITABINE HCL 200 MGCancer Treatment
J9202ZOLADEXGOSERELIN ACETATE IMPLANT PER 3.6 MGCancer Treatment
J9206CAMPTOSARINJECTION IRINOTECAN 20 MGCancer Treatment
J9208IFEXINJECTION IFOSFAMIDE 1 GCancer Treatment
J9209MESNEXINJECTION MESNA 200 MGCancer Treatment
J9211IDAMYCININJECTION IDARUBICIN HCL 5 MGCancer Treatment
J9223ZEPZELCALURBINECTEDINCancer Treatment
J9245ALKERANINJECTION MELINJECTION MELPHALAN HCL 50 MGCancer Treatment
J9261ARRANONINJECTION NELARABINE 50 MGCancer Treatment
J9266ONCASPARINJECTION PEGASPARGASE PER SINGLE DOSE VIALCancer Treatment
J9267TAXOLPACLITAXEL INJECTIONCancer Treatment
J9268NIPENTINJECTION PENTOSTATIN 10 MGCancer Treatment
J9280MUTAMYCINMITOMYCIN 5 MGCancer Treatment
J9281JELMYTOMITOMYCIN PYELOCALYCEAL SOLUTIONCancer Treatment
J9293NOVANTRONEINJECTION MITOXANTRONE HCL PER 5 MGCancer Treatment
J9316PHESGOPERTUZUMAB/TRASTUZUMAB/HYALURONIDASE-ZZXF INJECTIONCancer Treatment
J9317TRODELVYSACITUZUMAB GOVITECAN-HZIYCancer Treatment
J9320ZANOSARINJECTION STREPTOZOCIN 1 GCancer Treatment
J9351HYCAMTININJECTION TOPOTECAN 0.1 MGCancer Treatment
J9357VALSTARINJECTION VALRUBICIN INTRAVESICAL 200 MGCancer Treatment
J9360VELBANINJECTION VINBLASTINE SULFATE 1 MGCancer Treatment
J9370ONCOVINVINCRISTINE SULFATE 1 MGCancer Treatment
J9390NAVELBINEINJECTION VINORELBINE TARTRATE 10 MGCancer Treatment
J9395FASLODEXINJECTION FULVESTRANT 25 MGCancer Treatment
J9600PHOTOFRININJECTION PORFIMER SODIUM 75 MGCancer Treatment
Q2017VUMONTENIPOSIDE 50 MGCancer Treatment