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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