IL-5 INhiborors |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J2786 | Cinqair | For severe asthma aged 18 years and older with eosinophilic phenotype: Part D formulary inhaled corticosteroid | 12 months | N/A |
---|
J0517 | Fasenra | For severe asthma aged 18 years and older with eosinophilic phenotype: Part D formulary inhaled corticosteroid | 12 months | N/A |
---|
J2182 | Nucala | For severe asthma aged 18 years and older with eosinophilic phenotype: Part D formulary inhaled corticosteroid | 12 months | N/A |
---|
Xolair |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J2357 | Xolair | For moderate to severe persistent asthma aged 18 years and older: Part D formulary inhaled corticosteroid | 12 months | N/A |
---|
Tezspire |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J2356 | Tezspire | Part D formulary inhaled corticosteroid | 12 months | N/A |
---|
Ocular Angiogenesis Inhibitors |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J0179 | Beovu | (Part B) Avastin | 12 months | N/A |
---|
Q5124 | Byooviz | (Part B) Avastin
| 12 months
| N/A |
---|
Q5128 | Cimerli | (Part B) Avastin | 12 months | N/A |
---|
J0178 | Eylea | (Part B) Avastin | 12 months | N/A |
---|
J0177 | Eylea HD | (Part B) Avastin
| 12 months | N/A
|
---|
J2778 | Lucentis | (Part B) Avastin | 12 months
| N/A |
---|
J2779 | Susvimo | (Part B) Avastin | 12 months | N/A |
---|
J2777 | Vabysmo | (Part B) Avastin | 12 months | N/A |
---|
Healthcare Administered MS Agents |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J0202 | Lemtrada | TWO of the following: (Part D) Avonex, Betaseron, dimethyl, fumarate, fingolimod, glatiramer, (brand names Copaxone and, Glatopa), Mayzent, Plegridy, Vumerity | 12 months | N/A |
---|
J2350 | Ocrevus | TWO of the following: (Part D) Avonex, Betaseron, dimethyl fumarate, fingolimod, glatiramer (brand names Copaxone and Glatopa), Mayzent, Plegridy, Vumerity | 12 months | N/A |
---|
J2323 | Tysabri | For MS, TWO of the following: (Part D) Avonex, Betaseron, dimethyl fumarate, fingolimod, glatiramer (brand names Copaxone and Glatopa), Mayzent, Plegridy, Vumerity;
For Crohn's Disease ONE of the following: (Part D) Corticosteroids, methotrexate, and immunomodulators such as azathioprine or 6-mercaptopurine
| 12 months | N/A |
---|
Intra-articular Hyalronan Injections |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J7318 | Durolane | (Part B) Orthovisc, Synvisc/Synvisc One | 6 months | L39260 |
---|
J7323 | Euflexxa | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7326 | Gel-One | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7328 | Gelsyn-3 | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7320 | GenVisc 850 | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7321 | Hyalgan | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7322 | Hymovis | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7327 | Monovisc | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7321 | Supartz FX | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7332 | Triluron | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7329 | TriVisc | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months
| L39260 |
---|
J7321 | Visco-3 | (Part B) Orthovisc, Synvisc/Synvisc One
| 6 months | L39260 |
---|
IV Iron Agents |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J1439 | Injectafer (ferric carboxymaltose)*** | TWO of the following: (Part B) Venofer (iron sucrose), INFeD (iron dextran), Ferrlecit (sodium ferric gluconate complex), Feraheme (ferumoxytol), ferumoxytol | 12 months | N/A |
---|
J1437 | Monoferric (ferric derisomaltose)*** | TWO of the following: (Part B) Venofer (iron sucrose), INFeD (iron dextran), Ferrlecit (sodium ferric gluconate complex), Feraheme (ferumoxytol), ferumoxytol | 12 months | N/A |
---|
Bevacizumab (Oncology) |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
Q5126 | Alymsys | Mvasi, Zirabev | 12 months | N/A |
---|
J9035 | Avastin | Mvasi, Zirabev (only for oncology indications) | 12 months | N/A |
---|
Trastuzumab |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J9355 | Herceptin | Kanjinti, Ogivri | 12 months | N/A |
---|
J9356 | Herceptin Hylecta | Kanjinti, Ogivri | 12 months | N/A |
---|
Q5113 | Herzuma | Kanjinti, Ogivri | 12 months | N/A |
---|
Q5112 | Ontruzant | Kanjinti, Ogivri | 12 months | N/A |
---|
Q5116 | Trazimera | Kanjinti, Ogivri | 12 months | N/A |
---|
Rituximab |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
Q5123 | Riabni | Ruxience, Truxima | 12 months | L35026 |
---|
J9312 | Rituxan | Ruxience, Truxima | 12 months | L35026 |
---|
J9311 | Rituxan Hycela | Ruxience, Truxima | 12 months | L35026 |
---|
Long-Acting Colony Stimulating Factors |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
Q5108 | Fulphila | Udenyca, Ziextenzo | 12 months | L37176 |
---|
J2506 | Neulasta, Neulasta OnPro | Udenyca, Ziextenzo | 12 months | L37176 |
---|
Q5122 | Nyvepria | Udenyca, Ziextenzo | 12 months | L37176 |
---|
J1449 | Rolvedon | Udenyca, Ziextenzo | 12 months | A56748 |
---|
Short-Acting Colony Stimulating Factors |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J1447 | Granix | Zarxio, Nivestym | 12 months | L37176 |
---|
Q5125 | Releuko | Zarxio, Nivestym | 12 months | L37176 |
---|
J1442 | Neupogen | Zarxio, Nivestym | 12 months | L37176 |
---|
Soliris |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J1300 | Soliris | For Paroxysmal nocturnal hemoglobinuria: Ultomiris, Empaveli; For atypical hemolytic uremic syndrome: Ultomiris; For generalized myasthenia gravis: Ultomiris, Vyvgart; For neuromyelitis optica spectrum disorder: Enspryng, Uplizna | 12 months | N/A |
---|
Infliximab |
---|
HCPCS | Medication | Preferred Medication(s)** | Length of Approval | NCD / LCD |
---|
J1745 | Remicade | (Part B) Avsola, Inflectra | 12 months | N/A |
---|
Q5104 | Renflexis | (Part B) Avsola, Inflectra | 12 months | N/A |
---|