On January 11, 2018, Procedure Code Q9989 - Stelara was removed from the Injectable Drug List. It is no longer a valid code. All other changes below are effective January 12, 2018.
Starting on January 12, 2018, the drugs listed in the chart below will be added to the list of drugs in EmblemHealth’s Injectable Drug Utilization Management Program.
That means you must get prior approval before writing prescriptions for these drugs, and get reapproval if these drugs were already prescribed to your patients.
For approvals, please contact Accredo: 855-216-2166, Monday to Friday, 8 a.m. to 11 p.m.; Saturdays, 8 a.m. to 5 p.m.
| Drug Brand Name | Drug Generic Name | Procedure Code |
|---|---|---|
| Actemra | Tocilizumab | J3262 |
| Acthar_hp | Corticotropin | J0800 |
| Aldurazyme | Laronidase | J1931 |
| Benlysta | Belimumab | J0490 |
| Berinert | C1 esterase inhibitor (human) | J0597 |
| Cerezyme | Imiglucerase | J1786 |
| Cimzia | Certolizumab pegol | J0717 |
| Cinryze | C1 esterase inhibitor (human) | J0598 |
| Elaprase | Idursulfase | J1743 |
| Elelyso | Taliglucerase alfa | J3060 |
| Entyvio | Vedolizumab | J3380 |
| Eylea | Aflibercept | J0178 |
| Fabrazyme | Agalsidase beta | J0180 |
| Fusilev | Levoleucovorin calcium | J0641 |
| Halaven | Eribulin | J9179 |
| Hizentra | Subcutaneous immune globulin | J1559 |
| Hyqvia | Subcutaneous immune globulin | J1575 |
| Inflectra | Infliximab-dyyb | Q5102 |
| Jevtana | Cabazitaxel | J9043 |
| Kadcyla | Ado-trastuzumab emtansine | J9354 |
| Keytruda | Pembrolizumab | J9271 |
| Lemtrada | Alemtuzumab | J0202 |
| Lucentis | Ranibizumab | J2778 |
| Lumizyme | Alglucosidase alfa | J0221 |
| Naglazyme | Galsulfase | J1458 |
| Nplate | Romiplostim | J2796 |
| Opdivo | Nivolumab | J9299 |
| Perjeta | Pertuzumab | J9306 |
| Prolia | Denosumab | J0897 |
| Simponi aria | Golimumab | J1602 |
| Stelara | Ustekinumab | J3357, Q9989 |
| Tysabri | Natalizumab | J2323 |
| Vpriv | Velaglucerase alfa | J3385 |
| Xeomin | Incobotulinumtoxina | J0588 |
| Xgeva | Denosumab | J0897 |
| Yervoy | Ipilimumab | J9228 |