Políticas - Rx Parte B
Esta sección contiene los criterios clínicos para los medicamentos y terapias inyectables, en infusión o implantados cubiertos por el beneficio médico, que están sujetos a autorización previa. Los criterios clínicos se desarrollan para ayudar a guiar el uso clínicamente apropiado de medicamentos y terapias y son revisados y aprobados por el Comité de Farmacia y Terapéutica (P&T). El Comité de Farmacia y Terapéutica es un comité independiente y externo que incluye médicos practicantes, farmacéuticos y clínicos de los principales centros médicos académicos y prácticas clínicas con experiencia en medicina basada en la evidencia.
| Brand Name | Generic Name | HCPCS Code | Policy Name | Policy Number |
|---|---|---|---|---|
| Abraxane | Paclitaxel | J9264 | Paclitaxel, Protein Bound (Abraxane®) | MP-RX-FP-69-23 |
| Abrilada | Adalimumab-afzb | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Actemra | Tocilizumab | J3262 | Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) | MP-RX-FP-59-23 |
| Adcetris | Brentuximab | J9042 | Brentuximab vedotin (Adcetris®) | MP-RX-FP-01-23 |
| Advate | Antihemophilic Factor (Rcmb) Plasma/Albumin Free (rAHF-PFM) | J7192 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Adynovate | Antihemophilic Factor (Recombinant) Pegylated | J7207 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Afstyla | Antihemophilic Factor (Recombinant) Single Chain | J7210 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Aimovig | Erenumab | C9399; J3490; J3590 | CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) | MP-RX-FP-17-23 |
| Ajovy | Fremanezumab-vfrm | J3031 | CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) | MP-RX-FP-17-23 |
| Akynzeo | Netupitant, palonosetron | J8655 | Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) | LCD: L33827 - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) |
| Alimta | Pemetrexed | J9305 | Pemetrexed (Alimta®, Pemfexy®) | MP-RX-FP-05-23 |
| Alphanate | Antihemophilic viii/vwf comp | J7186 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| AlphaNine | Coagulation Factor IX | J7193 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Alprolix | Coagulation Factor IX (Recomb) Fc Fusion Protein (rFIXFc) | J7201 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Altuviio | Factor VIII/von Willebrand factor complex, recombinant | J7214 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Amjevita | Adalimumab-atto | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Aralast | Alpha1-Proteinase Inhibitor (Human) | J0256 | Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] | MP-RX-FP-06-23 |
| Aranesp (Albumin Free) | Darbepoetin alfa, non-esrd | J0881 | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Aranesp (Albumin Free) | Darbepoetin alfa, esrd use | J0882 | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Atgam | Lymphocyte Immune Globulin,Anti-Thymocyte Globulin (Equine) | J7504 | Antithymocyte Globulin Equine, (Atgam) | MP-RX-FP-08-24 |
| Avastin | Bevacizumab | J9035 | Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) | MP-RX-FP-13-23 |
| Avsola | Infliximab-axxq | Q5121 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Bavencio | Avelumab | J9023 | Avelumab (Bavencio®) | MP-RX-FP-09-23 |
| Belrapzo | Bendamustine | J9036 | Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) | MP-RX-FP-10-23 |
| Bendeka | Bendamustine | J9034, J9058, J9059 | Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) | MP-RX-FP-10-23 |
| BeneFix | Coagulation Factor IX (Recombinant) | J7195 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Benlysta | Belimumab | J0490 | Benlysta (belimumab) | MP-RX-FP-11-23 |
| Beovu | Brolucizumab-dbll | J0179 | Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] | MP-RX-FP-100-23 |
| Berinert | C1 Esterase Inhibitor (Human) | J0597 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Besponsa | Inotuzumab | J9229 | Inotuzumab ozogamicin (Besponsa®) | MP-RX-FP-12-23 |
| Blincyto | Blinatumomab | J9039 | Blinatumomab (Blyncito®) | MP-RX-FP-14-23 |
| Bonsity | Teriparatide | J3110 | Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) | MP-RX-FP-37-23 |
| Botox | OnabotulinumtoxinA | J0585 | Botulinum Toxins | LCD: L33274 - Botulinum Toxins |
| Cabenuva | Cabotegravir & Rilpivirine | J0741 | Cabotegravir extended-release; rilpivirine extended-release (Cabenuva) | MP-RX-FP-16-23 |
| Cerezyme | Imiglucerase | J1786 | Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) | MP-RX-FP-29-23 |
| Cimzia | Certolizumab pegol | J0717 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Cinqair | Reslizumab | J2786 | Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] | MP-RX-FP-58-23 |
| Cinryze | C1 Esterase Inhibitor (Human) | J0598 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Coagadex | Coagulation Factor X (Human) | J7175 | Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] | MP-RX-FP-82-23 |
| Corifact | Factor XIII Concentrate (Human) | J7180 | Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] | MP-RX-FP-82-23 |
| Cosentyx | Secukinumab | C9399; J3490; J3590 | Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] | MP-RX-FP-60-23 |
| Cyltezo | Adalimumab-adbm | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Cyramza | Ramucirumab | J9308 | Ramucirumab (Cyramza®) | MP-RX-FP-20-23 |
| Darzalex | Daratumumab | J9145 | Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) | MP-RX-FP-21-23 |
| Darzalex Faspro | Daratumumab and hyaluronidase-fijh | J9144 | Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) | MP-RX-FP-21-23 |
| Duopa | Carbidopa-Levodopa | J7340 | Carbidopa and levodopa enteral suspension (Duopa) | MP-RX-FP-22-23 |
| Dupixent | Dupilumab | C9399; J3490; J3590 | Dupilumab (Dupixent) | MP-RX-FP-23-23 |
| Durolane | Sodium Hyaluronate (Viscosupplement) | J7318 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Durysta | Bimatoprost | J7351 | Durysta [Bimatoprost Implant] | MP-RX-FP-24-23 |
| Dysport | AbobotulinumtoxinA | J0586 | Botulinum Toxins | LCD: L33274 - Botulinum Toxins |
| Egrifta | Tesamorelin Acetate | J3490; J3590 | Tesamorelin (Egrifta) | MP-RX-FP-25-23 |
| Elelyso | Taliglucerase Alfa | J3060 | Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) | MP-RX-FP-29-23 |
| Eligard | Leuprolide | J9217 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Eloctate | Antihemophilic Factor (Recombinant) Fc Fusion Protein(BDD-rFVIIIFc) | J7205 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Emend | Aprepitant, oral | J8501 | Oral antiemetic drugs: Aprepitant | MP-RX-FP-07-23 |
| Emgality | Galcanezumab | C9399; J3490; J3590 | CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) | MP-RX-FP-17-23 |
| Empliciti | Elotuzumab | J9176 | Elotuzumab (Empliciti®) | MP-RX-FP-26-23 |
| Enbrel | Etanercept | J1438 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Enhertu | fam-trastuzumab deruxtecan-nxk | J9358 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Entyvio | Vedolizumab | J3380 | Vedolizumab (Entyvio) | MP-RX-FP-28-23 |
| Epogen | Epoetin alfa, esrd | Q4081 | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Epogen | Epoetin alfa, non-esrd | J0885 | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Erbitux | Cetuximab | J9055 | Cetuximab (Erbitux®) | MP-RX-FP-30-23 |
| Erelzi | Etanercept-szzs | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Esperoct | Antihemophilic Factor (Recombinant) Glycopegylated-exei | J7204 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Eticovo | Etanercept-ykro | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Euflexxa | Sodium Hyaluronate (Viscosupplement) | J7323 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Evenity | Romosozumab-aqqg | J3111 | Romosozumab (Evenity) | MP-RX-FP-32-23 |
| Eylea | Aflibercept | J0178 | Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] | MP-RX-FP-100-23 |
| Fasenra | Benralizumab | J0517 | Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] | MP-RX-FP-58-23 |
| Fasenra Pen | Benralizumab | J0517 | Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] | MP-RX-FP-58-23 |
| Feiba NF | Antiinhibitor Coagulant Complex | J7198 | Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] | MP-RX-FP-82-23 |
| Fensolvi | Leuprolide | J1951 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Feraheme | Ferumoxytol | Q0138 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| Ferrlecit | Sodium ferric gluconate/sucrose complex | J2916 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| Fibryga | Fibrinogen Concentrate (Human) | J7177 | Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] | MP-RX-FP-82-23 |
| Firazyr | Icatibant Acetate | J1744 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Firmagon | Firmagon | J9155 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Firmagon (240 MG Dose) | Degarelix | J9155 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Forteo | Teriparatide (Recombinant) | J3110 | Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) | MP-RX-FP-37-23 |
| Fulphila | Pegfilgrastim-jmdb | Q5108 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Gammagard | Gammagard liquid injection | J1569 | Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] | MP-RX-FP-40-23 |
| Gammagard S/D | Immune Globulin (Human) IV | J1566 | Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] | MP-RX-FP-40-23 |
| Gamunex | Immune Globulin (Human) IV | J1561 | Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] | MP-RX-FP-40-23 |
| Gazyva | Obinutuzumab | J9301 | Obinutuzumab (Gazyva®) | MP-RX-FP-33-23 |
| Gel-One | Cross-Linked Hyaluronate | J7326 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Gel-Syn | Hyaluronan or derivative, for intra-articular injection | J7328 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| GenVisc 850 | Sodium Hyaluronate (Viscosupplement) | J7320 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Glassia | Alpha1-Proteinase Inhibitor (Human) | J0257 | Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] | MP-RX-FP-06-23 |
| Granix | Tbo-Filgrastim | J1447 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Hadlima | Adalimumab-bwwd | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Haegarda | C1 Esterase Inhibitor (Human) | J0599 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Halaven | Eribulin | J9179 | Eribulin mesylate (Halaven®) | MP-RX-FP-35-23 |
| Hemlibra | Emicizumab-kxwh | J7170 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Hemofil-M | Antihemophilic Factor (Human) | J7190 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Herceptin | Trastuzumab | J9355 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Herceptin Hylecta | Trastuzumab, and hyaluronidase-oysk | J9356 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Herzuma | Trastuzumab-pkrb | Q5113 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Hulio | Adalimumab-fkjp | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Humalog®, Humulin®, Novolin®, Novolog®, Insulin Lispro®, Apidra Solostar® | Insulin Lispro or Aspart for insulin pump use | J1817, S5550, S5551 | Infusion Pumps | NCD: 280.14 - Infusion Pumps |
| Humate-P | Antihemophilic Factor/von Willebrand Factor Complex (Human) | J7187 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Humira | Adalimumab | J0135 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Hyalgan | Sodium Hyaluronate (Viscosupplement) | J7321 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Hymovis | Hyaluronan | J7322 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Hyqvia | Immune Globulin (Human)-Hyaluronidase (Human Recombinant) | J1575 | Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] | MP-RX-FP-40-23 |
| Hyrimoz | Adalimumab-adaz | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Idacio | Adalimumab-aacf | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Idelvion | Coagulation Factor IX Recomb Albumin Fusion Protein (rIX-FP) | J7202 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Ilumya | Tildrakizumab-asmn | J3245 | Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] | MP-RX-FP-61-23 |
| Iluvien | Fluocinolone acetonide intravitreal implant | J7313 | Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] | MP-RX-FP-43-23 |
| Imfinzi | Durvalumab | J9173 | Durvalumab (Imfinzi®) | MP-RX-FP-39-23 |
| Infed | Iron dextran | J1750 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| Inflectra | Infliximab-dyyb | Q5103 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Infliximab | Infliximab | J1745 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Injectafer | Ferric carboxymaltose | J1439 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| ISTODAX | Romidepsin | J9319 | Romidepsin (Istodax®) | MP-RX-FP-45-23 |
| IXEMPRA | Ixabepilone | J9207 | Ixabepilone (Ixempra®) | MP-RX-FP-46-23 |
| Ixifi | Infliximab-qbtx | Q5109 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Ixinity | Coagulation Factor IX (Recombinant) | J7195 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Jevtana | Cabazitaxel | J9043, J9064 | Cabazitaxel (Jevtana®) | MP-RX-FP-47-23 |
| Jivi | Antihemophilic Factor (Recombinant) PEGylated-aucl (BDD-rFVIII PEG-aucl) | J7208 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Kadcyla | ado-trastuzumab emtansine | J9354 | Ado-trastuzumab (Kadcyla®) | MP-RX-FP-48-23 |
| Kalbitor | Ecallantide | J1290 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Kanjinti | Trastuzumab | Q5117 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Kevzara | Sarilumab | C9399; J3490; J3590 | Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) | MP-RX-FP-59-23 |
| Keytruda | Pembrolizumab | J9271 | Pembrolizumab (Keytruda®) | MP-RX-FP-49-23 |
| Koate | Antihemophilic Factor (Human) | J7190 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Kogenate FS | Antihemophilic Factor (Recombinant) (rFVIII) | J7192 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Kovaltry | Antihemophilic Factor (Recombinant) Plasma/Albumin Free (rAHF-PFM) | J7211 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Krystexxa | Pegloticase | J2507 | Krystexxa (pegloticase) | MP-RX-FP-50-23 |
| Kyprolis | Carfilzomib | J9047 | Carfilzomib (Kyprolis®) | MP-RX-FP-51-23 |
| Lanreotide | Lanreotide (cipla) | J1932 | Lanreotide (Somatuline Depot) | MP-RX-FP-83-23 |
| Lemtrada | Alemtuzumab | J0202 | Alemtuzumab [Lemtrada] | MP-RX-FP-52-23 |
| Leqvio | Inclisiran, 1 mg | J1306 | Inclisiran [Leqvio] | MP-RX-FP-53-23 |
| Libtayo | cemiplimab-rwlc | J9119 | Cemiplimab-rwlc (Libtayo®) | MP-RX-FP-54-23 |
| Lucentis | Ranibizumab | J2778 | Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] | MP-RX-FP-100-23 |
| Lunsumio | mosunetuzumab-axgb | J9350 | Mosunetuzumab-axgb (Lunsumio®) | MP-RX-FP-55-23 |
| Lupaneta | Leuprolide | J1950 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Lupron Depot (1-Month) | Leuprolide | J1950 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Lupron Depot (3-Month) | Leuprolide | J9217 (Non-Oncology), J1950 (Oncology) | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Lupron Depot (6-Month) | Leuprolide | J9217 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Margenza | Margetuximab | J9353 | Margetuximab-cmkb (Margenza®) | MP-RX-FP-56-23 |
| Monjuvi | Tafasitamab | J9349 | Tafasitamab-cxix (Monjuvi®) | MP-RX-FP-57-23 |
| Monoferric | Ferric derisomaltose | J1437 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| Monovisc | Hyaluronan | J7327 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Mvasi | Bevacizumab | Q5107 | Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) | MP-RX-FP-13-23 |
| MYCOPHENOLATE MOFETIL ORAL | Mycophenolate mofetil | J7517 | Immunosuppressive Drugs | LCD - Immunosuppressive Drugs (L33824) (cms.gov) |
| MYCOPHENOLATE SODIUM | Mycophenolic acid | J7518 | Immunosuppressive Drugs | LCD - Immunosuppressive Drugs (L33824) (cms.gov) |
| Mylotarg | gemtuzumab ozogamicin | J9203 | Gemtuzumab ozogamicin (Mylotarg®) | MP-RX-FP-62-23 |
| Myobloc | RimabotulinumtoxinB | J0587 | Botulinum Toxins | LCD: L33274 - Botulinum Toxins |
| Neulasta | Pegfilgrastim | J2506 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Neupogen | Filgrastim | J1442 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Nivestym | Filgrastim-aafi | Q5110 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Novoeight | Antihemophilic Factor VIII (Recombinant) BD Truncated (BD trunc-rFVIII) | J7182 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| NovoSeven RT | Coagulation Factor VIIa (Recombinant) | J7189 | Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] | MP-RX-FP-82-23 |
| Nplate | Romiplostim | J2796 | Romiplostim (Nplate) | MP-RX-FP-63-23 |
| Nucala | Mepolizumab | J2182 | Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] | MP-RX-FP-58-23 |
| Nuwiq | Antihemophilic Factor (Rcmb) Simoctocog alfa(BDD-rFVIII,sim) | J7209 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Nyvepria | Pegfilgrastim-apgf | Q5122 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Obizur | Antihemophilic Factor (Recombinant Porcine) (rpFVIII) | J7188 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Ocrevus | Ocrelizumab | J2350 | Ocrelizumab [Ocrevus] | MP-RX-FP-64-23 |
| OGIVRI | Trastuzumab-dkst | Q5114 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Ontruzant | trastuzumab-dttb | Q5112 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Opdivo | Nivolumab | J9299 | Nivolumab (Opdivo®) | MP-RX-FP-66-23 |
| OPDUALAG | nivolumab and relatlimab-rmbw | J9298 | Nivolumab and relatlimab-rmbw (Opdualag®) | MP-RX-FP-67-23 |
| Orencia | Abatacept | J0129 | Orencia (abatacept) | MP-RX-FP-68-23 |
| Orladeyo | Berotralstat HCl | J8499 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Orthovisc | Hyaluronan | J7324 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Ozurdex | Dexamethasone intravitreal implant | J7312 | Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] | MP-RX-FP-43-23 |
| PACLitaxel Protein-Bound Part | Paclitaxel | J9264 | Paclitaxel, Protein Bound (Abraxane®) | MP-RX-FP-69-23 |
| Padcev | Enfortumab | J9177 | Enfortumab vedotin-ejfv (Padcev®) | MP-RX-FP-70-23 |
| Panzyga | Ivig non-lyophilized, nos | J1599 | Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] | MP-RX-FP-40-23 |
| PEMETREXED | Pemetrexed | J9314, J9322, J9323, J9294, J9296, J9297 | Pemetrexed (Alimta®, Pemfexy®) | MP-RX-FP-05-23 |
| Pemfexy | Pemetrexed | J9304 | Pemetrexed (Alimta®, Pemfexy®) | MP-RX-FP-05-23 |
| Perjeta | Pertuzumab | J9306 | Pertuzumab (Perjeta®) | MP-RX-FP-71-23 |
| Phesgo | pertuzumab, trastuzumab, and hyaluronidase-zzxf, | J9316 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Polivy | Polatuzumab | J9309 | Polatuzumab vedotin-piiq (Polivy®) | MP-RX-FP-73-23 |
| Privigen | Inj ivig privigen 500 mg | J1459 | Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] | MP-RX-FP-40-23 |
| Procrit | Epoetin alfa, non-esrd | J0885 | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Procrit | Epoetin alfa, 100 units esrd | Q4081 | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Profilnine | Factor IX Complex | J7194 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Prolastin | Alpha1-Proteinase Inhibitor (Human) | J0256 | Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] | MP-RX-FP-06-23 |
| Radicava | Edaravone | J1301 | Radicava (edaravone) | MP-RX-FP-75-23 |
| Rebinyn | Coagulation Factor IX (Recombinant) Glycopegylated | J7203 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Reblozyl | Luspatercept-aamt | J0896 | Luspatercept (Reblozyl) | MP-RX-FP-76-23 |
| Recombinate | Antihemophilic Factor (Recombinant) | J7192 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Remicade | Infliximab | J1745 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Renflexis | Infliximab-abda | Q5104 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Retacrit | Inj retacrit esrd on dialysi | Q5105 | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
| Retisert | Fluocinolone acetonide intravitreal implant | J7311 | Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] | MP-RX-FP-43-23 |
| Riabni | Rituximab | Q5123 | Rituximab Agents for Non-Oncology and Oncology-Related Indications | MP-RX-FP-78-23 |
| RiaSTAP | Fibrinogen Concentrate (Human) | J7178 | Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] | MP-RX-FP-82-23 |
| Rituxan | Rituximab | J9312 | Rituximab Agents for Non-Oncology and Oncology-Related Indications | MP-RX-FP-78-23 |
| Rixubis | Coagulation Factor IX (Recombinant) | J7200 | Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] | MP-RX-FP-03-23 |
| Rolvedon | Eflapegrastim-xnst | J1449 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Ruconest | C1 Esterase Inhibitor (Recombinant) | J0596 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Ruxience | Rituximab | Q5119 | Rituximab Agents for Non-Oncology and Oncology-Related Indications | MP-RX-FP-78-23 |
| Rybrevant | amivantamab-vmjw | J9061 | Amivantamab-vmjw (Rybrevant®) | MP-RX-FP-79-23 |
| Sajazir | Icatibant Acetate | J1744 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| SandoSTATIN | Octreotide injection, non-depot | J2354 | Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) | MP-RX-FP-65-23 |
| SandoSTATIN LAR Depot | Octreotide injection, depot | J2353 | Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) | MP-RX-FP-65-23 |
| Saphnelo | Anifrolumab-fnia | J0491 | Saphnelo (anifrolumab-fnia) | MP-RX-FP-80-23 |
| Sarclisa | Isatuximab | J9227 | isatuximab (Sarclisa®) | MP-RX-FP-81-23 |
| SevenFact | Coagulation Factor VIIa (Recombinant)-jncw | J7212 | Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] | MP-RX-FP-82-23 |
| Siliq | brodalumab | C9399; J3490; J3590 | Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] | MP-RX-FP-60-23 |
| Simponi | Golimumab | J1602 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Simponi Aria | Golimumab | J1602 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Skyrizi IV | Risankizumab-rzaa | J2327 | Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] | MP-RX-FP-61-23 |
| Soliris | Eculizumab | J1300 | Complement Inhibitors: Soliris [eculizumab], Ultomiris [ravulizumab-cwvz] | MP-RX-FP-19-23 |
| Somatuline Depot | Lanreotide Acetate | J1930 | Lanreotide (Somatuline Depot) | MP-RX-FP-83-23 |
| Spinraza | Nusinersen | J2326 | Spinraza (nusinersen) | MP-RX-FP-84-23 |
| Stelara IV | Ustekinumab, iv inject, 1 mg | J3358 | Stelara (ustekinumab) | MP-RX-FP-85-23 |
| Stelara SQ | Ustekinumab sub cu inj, 1 mg | J3357 | Stelara (ustekinumab) | MP-RX-FP-85-23 |
| Supprelin | Leuprolide | J9217 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Syfovre | Pegcetacoplan | J2781 | Syfovre (pegcetacoplan) | MP-RX-FP-86-23 |
| Sylvant | Siltuximab | J2860 | Sylvant (siltuximab) | MP-RX-FP-87-23 |
| Synojoynt | Sodium Hyaluronate (Viscosupplement) | J7331 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Synvisc | Hylan | J7325 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Synvisc-One | Hylan | J7325 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| TACROLIMUS IMME REL ORAL 1MG | Tacrolimus immediate release | J7507 | Immunosuppressive Drugs | LCD - Immunosuppressive Drugs (L33824) (cms.gov) |
| Takhzyro | Lanadelumab-flyo | J0593 | Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo | MP-RX-FP-36-23 |
| Taltz | Ixekizumab | C9399; J3490; J3590 | Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] | MP-RX-FP-60-23 |
| Tecentriq | Atezolizumab | J9022 | Atezolizumab (Tecentriq) | MP-RX-FP-88-23 |
| Tepezza | Teprotumumab-trbw | J3241 | Teprotumumab-trbw (Tepezza) | MP-RX-FP-89-23 |
| Tezspire | Tezepelumab-ekko | J2356 | Tezepelumab-ekko (Tezspire) | MP-RX-FP-90-23 |
| Torisel | Temsirolimus | J9330 | Temsirolimus (Torisel®) | MP-RX-FP-91-23 |
| Trazimera | Trastuzumab-qyyp | Q5116 | Trastuzumab – Trastuzumab Biologics | LCD: L34026 - Trastuzumab – Trastuzumab Biologics |
| Treanda | Bendamustine | J9033 | Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) | MP-RX-FP-10-23 |
| TRELSTAR | Triptorelin | J3315 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Tremfya | Guselkumab | J1628 | Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] | MP-RX-FP-61-23 |
| Triesence | Triamcinolone acetonide preservative-free | J3300 | Triamcinolone acetonide injectable suspensión [Xipere, Triesence] | MP-RX-FP-93-23 |
| Triferic | Ferric pyrophosphate citrate | J1443 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| Triferic AVNU | Ferric pyrophosphate citrate | J1445 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| Triluron | Sodium Hyaluronate (Viscosupplement) | J7332 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Trivisc | Sodium Hyaluronate (Viscosupplement) | J7329 | Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] | MP-RX-FP-38-23 |
| Trodelvy | Sacituzumab | J9317 | Sacituzumab govitecan (Trodelvy®) | MP-RX-FP-94-23 |
| Trogarzo | Ibalizumab-uiyk | J1746 | Ibalizumab-uiyk (Trogarzo) | MP-RX-FP-95-23 |
| Truxima | Rituximab | Q5115 | Rituximab Agents for Non-Oncology and Oncology-Related Indications | MP-RX-FP-78-23 |
| Tymlos | Abaloparatide | C9399; J3490; J3590 | Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) | MP-RX-FP-37-23 |
| Tysabri | Natalizumab | J2323 | Natalizumab (Tysabri) | MP-RX-FP-97-23 |
| Udenyca | Pegfilgrastim-cbqv | Q5111 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Ultomiris | Ravulizumab-cwvz | J1303 | Complement Inhibitors: Soliris [eculizumab], Ultomiris [ravulizumab-cwvz] | MP-RX-FP-19-23 |
| Uplizna | Inebilizumab-cdon | J1823 | Uplizna (inebilizumab-cdon) | MP-RX-FP-98-23 |
| Vabysmo | Faricimab-svoa | J2777 | Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] | MP-RX-FP-100-23 |
| Vectibix | Panitumumab | J9303 | Panitumumab (Vectibix®) | MP-RX-FP-99-23 |
| Venofer | Iron sucrose | J1756 | Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) | MP-RX-FP-44-23 |
| Vimizim | Elosulfase Alfa | J1322 | Vimizim (elosulfase alfa) | MP-RX-FP-102-23 |
| Visudyne | Verteporfin | J3396 | Verteporfin [Visudyne] | MP-RX-FP-101-23 |
| Vivimusta | Bendamustine | J9056 | Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) | MP-RX-FP-10-23 |
| Vonvendi | Von Willebrand Factor (Recombinant) | J7179 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Vpriv | Velaglucerase Alfa | J3385 | Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) | MP-RX-FP-29-23 |
| Vyepti | Eptinezumab-jjmr | J3032 | Eptinezumab-jjmr (Vyepti) | MP-RX-FP-103-23 |
| Wilate | Antihemophilic Factor/von Willebrand Factor Complex (Human) | J7183 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Xeomin | IncobotulinumtoxinA | J0588 | Botulinum Toxins | LCD: L33274 - Botulinum Toxins |
| Xiaflex | Collagenase Clostridium Histolyticum | J0775 | Xiaflex (collagenase clostridium histolyticum) injection | MP-RX-FP-104-23 |
| Xipere | Triamcinolone acetonide | J3301 | Triamcinolone acetonide injectable suspension [Xipere, Triesence] | MP-RX-FP-93-23 |
| Xolair | Omalizumab | J2357 | Omalizumab [Xolair] | MP-RX-FP-105-23 |
| Xyntha Solofuse | Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) | J7192 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Xyntha | Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) | J7185 | Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] | MP-RX-FP-02-23 |
| Yervoy | Ipilimumab | J9228 | Ipilimumab (Yervoy®) | MP-RX-FP-106-23 |
| Yuflyma | Adalimumab-aaty | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Yusimry | Adalimumab-aqvh | J3490, J3590 | Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] | MP-RX-FP-96-23 |
| Yutiq | Fluocinolone acetonide intravitreal implant | J7314 | Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] | MP-RX-FP-43-23 |
| Zaltrap | Aflibercept | J9400 | Ziv-aflibercept (Zaltrap®) | MP-RX-FP-107-23 |
| Zarxio | Filgrastim-sndz | Q5101 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Zemaira | Alpha1-Proteinase Inhibitor (Human) | J0256 | Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] | MP-RX-FP-06-23 |
| Zepzelca | Lurbinectedin | J9223 | Lurbinectedin (Zepzelca®) | MP-RX-FP-108-23 |
| Ziextenzo | Pegfilgrastim-bmez | Q5120 | Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] | MP-RX-FP-18-23 |
| Zinplava | Bezlotoxumab | J0565 | Bezlotoxumab (Zinplava) | MP-RX-FP-109-23 |
| Zirabev | Bevacizumab | Q5118 | Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) | MP-RX-FP-13-23 |
| Zoladex | Goserelin | J9202 | GnRH analogs for non-oncology and oncology-related indications | MP-RX-FP-34-23 |
| Zynlonta | loncastuximab tesirine-lpyl | J9359 | Loncastuximab tesirine-lpyl (Zynlonta®) | MP-RX-FP-110-23 |
| Abecma | Idecabtagene vicleucel | Q2055 | Idecabtagene vicleucel (Abecma®) | MP-RX-FP-111-23 |
| Breyanzi | Lisocabtagene maraleucel | Q2054 | Lisocabtagene maraleucel (Breyanzi®) | MP-RX-FP-112-23 |
| Carvykti | Ciltacabtagene autoleucel | Q2056 | Ciltacabtagene autoleucel (Carvykti®) | MP-RX-FP-113-23 |
| Kymriah | Tisagenlecleucel | Q2042 | Tisagenlecleucel (Kymriah®) | MP-RX-FP-114-23 |
| Tecartus | Brexucabtagene autoleucel | Q2053 | Brexucabtagene autoleucel (Tecartus®) | MP-RX-FP-115-23 |
| Yescarta | axicabtagene ciloleucel | Q2041 | Axicabtagene ciloleucel (Yescarta®) | MP-RX-FP-116-23 |
Políticas de Manejo de Utilización Clínica
Las Políticas de Utilización Médica definen la manera en que MMM Holdings LLC y sus subsidiarias identifican y evalúan solicitudes de servicios específicos y facilitan un proceso de determinación consistente de acuerdo con las regulaciones de los Centros de Medicare y Medicaid (CMS).
| Medical Policy Title | Medical Policy Number |
|---|---|
| Ankle-Foot/Knee-Ankle-Foot Orthoses | MP-HO-FP-01-23 |
| Knee Orthoses | MP-HO-FP-02-23 |
| Cervical Traction Devices | MP-HO-FP-03-23 |
| External Breast Prostheses | MP-HO-FP-04-23 |
| Orthopedic Footwear | MP-HO-FP-05-23 |
| Pneumatic Compression Devices | MP-HO-FP-06-23 |
| Therapeutic Shoes for Persons with Diabetes | MP-HO-FP-07-23 |
| Lower Limb Prostheses | MP-HO-FP-08-23 |
| Spinal Orthoses: TLSO and LSO | MP-HO-FP-09-23 |
| Surgical Dressings | MP-HO-FP-10-23 |
| External Breast Prostheses | MP-HO-FP-11-23 |
| Knee Orthoses | MP-HO-FP-12-23 |
| Therapeutic Shoes for Persons with Diabetes | MP-HO-FP-13-23 |
| Orthopedic Footwear | MP-HO-FP-14-23 |
| Ankle-Foot/Knee-Ankle-Foot Orthosis | MP-HO-FP-15-23 |
| Lower Limb Prostheses | MP-HO-FP-16-23 |
| Spinal Orthoses: TLSO and LSO | MP-HO-FP-17-23 |
| Cervical Traction Devices | MP-HO-FP-18-23 |
| Pneumatic Compression Devices | MP-HO-FP-19-23 |
| Surgical Dressings | MP-HO-FP-20-23 |
| Sub-Acute Levels of Care (Skill Nursing and Rehab) | MP-HSIP-005-FP-01-23 |
| Abdominal Lipectomy/Panniculectomy | MP-SU-FP-02-23 |
| Bariatric Surgery | MP-SU-FP-03-23 |
| Stem Cell Transplantation Autologous/Allogenic | MP-SCT-FP-03-23 |
| Refractive Keratoplasty/Cornea Transplant | MP-CT-FP-05-23 |
| Heart/Lung Transplant | MP-HLT-FP-08-23 |
| Heart Transplants | MP-HT-FP-01-23 |
| Hyperbaric Oxygen Therapy | MP-HOT-FP-02-23 |
| Intestine and Multi-Visceral Transplantation | MP-IT-FP-06-23 |
| IV Antibiotics/Hydration Administration (IV)/External Infusion Pumps | MP-IV-FP-01-23 |
| Kidney Transplant | MP-KT-FP-09-23 |
| Adult Liver Transplantation | MP-LT-FP-02-23 |
| Lung Transplant | MP-LT-FP-07-23 |
| Pancreas Transplant | MP-PT-FP-04-23 |
| Skin Substitute Grafts | MP-SSG-FP-03-23 |
| Wound Care (Debridements, Wound Negative Pressure Therapy (Vac Therapy), Surgical Dressings) | MP-WC-FP-01-23 |
| Wound Electrical Stimulation and Electromagnetic Therapy | MP-WES-FP-04-23 |
| Occupational, Speech and Physical Therapy Guidelines | Occupational, Speech and Physical Therapy Guidelines |
| Psychiatric Diagnostic Evaluation and Psychotherapy Services | MP-EM-DP-02-23 |
| Neuropsychological Tests | MP-EM-DP-03-23 |
| GMT Medicare Crosswalk 2024 | GMT Medicare Crosswalk 2024 |
| Molecular Testing Review Criteria | Molecular Testing Review Criteria |
| Home Visits - Mental Health | MP-EM-FP-01-23 |
| Pre-Authorization Unit - Clinical Criteria | Pre-Authorization Unit Crosswalk Clinical Guidelines 04-24-2024 |
| Additional information available – please contact: | liz.roman@mso-pr.com and or sindia.Villegas@mso-pr.com |