Políticas Médicas

Nuestras políticas médicas definen la manera en que MMM Holdings LLC y sus subsidiarias identifican y evalúan solicitudes de servicios específicos mediante la aplicación de guías clínicas. Las políticas se adhieren a las guías de Determinaciones de Cobertura Nacional y Local (NCD o LCD) y/o los Artículos definidos por los Centros de Medicare y Medicaid (CMS) y/o cualquier otro criterio clínico. Las políticas reflejan la investigación científica actual y los estándares de guías clínicas basadas en esta evidencia.

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
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)
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
Anktiva	Nogapendekin alfa inbakicept-pmln	J9999	Anktiva_PartB_MedPol_2024	MP-RX-FP-154-24
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
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
Berinert	C1 Esterase Inhibitor (Human)	J0597	Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo	MP-RX-FP-36-23
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
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
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
Dodex	Cyanocobalamin	J3420	Vitamin B12 Injections	LCD - Vitamin B12 Injections (L33967) (cms.gov)
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
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
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
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
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
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
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
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
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
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
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
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)
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	avalglucosidase alfa-ngpt	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
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
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
Phesgo	pertuzumab, trastuzumab, and hyaluronidase-zzxf,	J9316	Trastuzumab – Trastuzumab Biologics	LCD: L34026 - Trastuzumab – Trastuzumab Biologics
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 (Including Rituxan Hycela®) 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 (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications	MP-RX-FP-78-23
Rituxan Hycela	Rituximab	J9311	Rituximab Agents (Including Rituxan Hycela®) 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 (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications	MP-RX-FP-78-23
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
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
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
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
Tepezza	Teprotumumab-trbw	J3241	Teprotumumab-trbw (Tepezza)	MP-RX-FP-89-23
Tezspire	Tezepelumab-ekko	J2356	Tezepelumab-ekko (Tezspire)	MP-RX-FP-90-23
Tevimbra	tislelizumab-jsgr	J3590, J9999	Tevimbra_PartB_MedPol_2024	MP-RX-FP-155-24
Trazimera	Trastuzumab-qyyp	Q5116	Trastuzumab – Trastuzumab Biologics	LCD: L34026 - Trastuzumab – Trastuzumab Biologics
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
Trogarzo	Ibalizumab-uiyk	J1746	Ibalizumab-uiyk (Trogarzo)	MP-RX-FP-95-23
Truxima	Rituximab	Q5115	Rituximab Agents (Including Rituxan Hycela®) 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
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
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	J3299	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
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
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
Abecma	Idecabtagene vicleucel	Q2055	Chimeric Antigen Receptor (CAR) T-cell Therapy	NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Breyanzi	Lisocabtagene maraleucel	Q2054	Chimeric Antigen Receptor (CAR) T-cell Therapy	NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Carvykti	Ciltacabtagene autoleucel	Q2056	Chimeric Antigen Receptor (CAR) T-cell Therapy	NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Kymriah	Tisagenlecleucel	Q2042	Chimeric Antigen Receptor (CAR) T-cell Therapy	NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Tecartus	Brexucabtagene autoleucel	Q2053	Chimeric Antigen Receptor (CAR) T-cell Therapy	NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Yescarta	axicabtagene ciloleucel	Q2041	Chimeric Antigen Receptor (CAR) T-cell Therapy	NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Alymsys	bevacizumab-maly	Q5126	Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)	MP-RX-FP-13-23
Avzivi	bevacizumab-tnjn	J3490, J3590	Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)	MP-RX-FP-13-23
Vegzelma	bevacizumab-adcd	Q5129	Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)	MP-RX-FP-13-23
Alymsys intravitreal	bevacizumab-maly	Q5126	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
Avastin intravitreal	bevacizumab	J9035	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
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
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
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
Mvasi intravitreal	bevacizumab-awwb	Q5107	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
Susvimo	Ranibizumab	J2779	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
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
Vegzelma intravitreal	bevacizumab-adcd	Q5129	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
Zirabev intravitreal	bevacizumab-bvzr	Q5118	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
Izervay	Avacincaptad Pegol	C9160	Avacincaptad pegol intravitreal solution (Izervay®)	MP-RX-FP-117-24
Adakveo	Crizanlizumab-tmca	J0791	Crizanlizumab-tmca (Adakveo®)	MP-RX-FP-118-24
Jemperli	Dostarlimab-gxly	J9272	Dostarlimab-gxly (Jemperli®)	MP-RX-FP-119-24
Elrexfio	Elranatamab-bcmm	J3490, J3590, J9999, C9165	Elranatamab-bcmm (Elrexfio®)	MP-RX-FP-120-24
Epkinly	Epcoritamab-bysp	J9321	Epcoritamab-bysp (Epkinly®)	MP-RX-FP-121-24
Columvi	Glofitamab-gxbm	J9286	Glofitamab-gxbm (Columvi®)	MP-RX-FP-122-24
Boniva	Ibandronate sodium injection	J1740	IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®), Xgeva®), Ibandronate IV (Boniva®)	MP-RX-FP-123-24
Prolia	Denosumab	J0897	IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®), Xgeva®), Ibandronate IV (Boniva®)	MP-RX-FP-123-24
Xgeva	Denosumab	J0897	IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®), Xgeva®), Ibandronate IV (Boniva®)	MP-RX-FP-123-24
Lumizyme	alglucosidase alfa	J0221	Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®)	MP-RX-FP-124-24
Nexviazyme	avalglucosidase alfa-ngpt	J0219	Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®)	MP-RX-FP-124-24
Pombiliti	cipaglucosidase alfa-atga	J3490, J3590, S9357	Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®)	MP-RX-FP-124-24
Omvoh	Mirikizumab-mrkz	J3590	Mirikizumab-mrkz (Omvoh®)	MP-RX-FP-125-24
Elahere	Mirvetuximab Soravtansine-gynx	J9063	Mirvetuximab soravtansine-gynx (Elahere®)	MP-RX-FP-126-24
Poteligeo	mogamulizumab-kpkc, 1 mg	J9204	Mogamulizumab-kpkc (Poteligeo®)	MP-RX-FP-127-24
Mozobil	plerixafor	J2562	Plerixafor (Mozobil®)	MP-RX-FP-128-24
Danyelza	Naxitamab-gqgk	J9348	Naxitamab-gqgk (Danyelza®)	MP-RX-FP-129-24
Zometa	Zoledronic	J3489	Zoledronic acid (Zometa®)	MP-RX-FP-130-24
Portrazza	necitumumab, 1 mg	J9295	Necitumumab (Portrazza®)	MP-RX-FP-131-24
Arzerra	Ofatumumab	J9302	Ofatumumab (Arzerra®)	MP-RX-FP-132-24
kimyrsa	oritavancin, 10mg	J2406	Oritavancin (Orbactiv®, Kimyrsa®)	MP-RX-FP-133-24
orbactiv	oritavancin, 10mg	J2407	Oritavancin (Orbactiv®, Kimyrsa®)	MP-RX-FP-133-24
Signifor	Pasireotide Diaspartate	C9399, J3490, J3590	Pasireotide (Signifor®, Singnifor LAR®)	MP-RX-FP-134-24
Signifor LAR	Pasireotide Pamoate	J2502	Pasireotide (Signifor®, Singnifor LAR®)	MP-RX-FP-134-24
Empaveli	Pegcetacoplan	J3490, C9399	Pegcetacoplan (Empaveli®)	MP-RX-FP-135-24
Veopoz	Pozelimab-bbfg	J3590, C9399	Pozelimab-bbfg (Veopoz®)	MP-RX-FP-136-24
Azedra	iobenguane I 131	A9590	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®)	MP-RX-FP-137-24
Lutathera	lutetium Lu 177 dotatate	A9513	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®)	MP-RX-FP-137-24
Pluvicto	Lutetium lu 177 vipivotide tetraxetan	A9607	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®)	MP-RX-FP-137-24
Zevalin Y-90	Ibritumomab Tiuxetan	A9543	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®)	MP-RX-FP-137-24
Zynyz	Retifanlimab-dlwr	J9345	Retifanlimab-dlwr (Zynyz®)	MP-RX-FP-138-24
Ryzneuta	efbemalenograstim alfa-vuxw	J3490, J3590	efbemalenograstim alfa-vuxw (Ryzneuta®)	MP-RX-FP-139-24
Spevigo	Spesolimab-sbzo	J1747	Spesolimab-sbzo (Spevigo®)	MP-RX-FP-140-24
Enjaymo	Sutimlimab-jome	J1302	Sutimlimab-jome (Enjaymo®)	MP-RX-FP-141-24
Talvey	Talquetamab-tgvs	J3490, J3590, J9999, C9163	Talquetamab-tgvs (Talvey®)	MP-RX-FP-142-24
Kimmtrak	Tebentafusp-tebn	J9274	Tebentafusp-tebn (Kimmtrak®)	MP-RX-FP-143-24
Tecvayli	Teclistamab-cqyv	J9380	Teclistamab-cqyv (Tecvayli®)	MP-RX-FP-144-24
Tivdak	Tisotumab Vedotin-tftv	J9273	Tisotumab vedotin-tftv (Tivdak®)	MP-RX-FP-145-24
Qalsody	Tofersen	J1304	Tofersen (Qalsody®)	MP-RX-FP-146-24
Loqtorzi	Toripalimab-tpzi	J3490, J3590, C9399	Toripalimab-tpzi (Loqtorzi®)	MP-RX-FP-147-24
Yondelis	Trabectedin	J9352	Trabectedin (Yondelis®)	MP-RX-FP-148-24
Adbry	Tralokinumab-ldrm	J3490, J3590, C9399	Tralokinumab-ldrm (Adbry®)	MP-RX-FP-149-24
Imjudo	Tremelimumab-actl	J9347	Tremelimumab-actl (Imjudo®)	MP-RX-FP-150-24
Briumvi	ublituximab-xiiy	J2329	Ublituximab-xiiy (Briumvi®)	MP-RX-FP-151-24
Reclast	Zoledronic	J3489	Zoledronic acid (Reclast®)	MP-RX-FP-152-24
Yervoy	Ipilimumab	J9228	Ipilimumab (Yervoy®)	MP-RX-FP-106-23
Zepzelca	Lurbinectedin	J9223	Lurbinectedin (Zepzelca®)	MP-RX-FP-108-23
Zynlonta	loncastuximab tesirine-lpyl	J9359	Loncastuximab tesirine-lpyl (Zynlonta®)	MP-RX-FP-110-23
Camcevi	Leuprolide mesylate	J1952	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
Eligard	Leuprolide	J9217	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
Fensolvi	Leuprolide	J1951	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
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
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
Supprelin	Leuprolide	J9217	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
TRELSTAR	Triptorelin	J3315	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
Triptodur	Triptorelin pamoate extended-release	J3316	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
Vantas	Histrelin	J9226	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
Zoladex	Goserelin	J9202	GnRH analogs for non-oncology and oncology-related indications	MP-RX-FP-34-23
Asceniv		J3590	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
ISTODAX	Romidepsin	J9319	Romidepsin (Istodax®)	MP-RX-FP-45-23
IXEMPRA	Ixabepilone	J9207	Ixabepilone (Ixempra®)	MP-RX-FP-46-23
Margenza	Margetuximab	J9353	Margetuximab-cmkb (Margenza®)	MP-RX-FP-56-23
Monjuvi	Tafasitamab	J9349	Tafasitamab-cxix (Monjuvi®)	MP-RX-FP-57-23
Mylotarg	gemtuzumab ozogamicin	J9203	Gemtuzumab ozogamicin (Mylotarg®)	MP-RX-FP-62-23
Sarclisa	Isatuximab	J9227	isatuximab (Sarclisa®)	MP-RX-FP-81-23
Torisel	Temsirolimus	J9330	Temsirolimus (Torisel®)	MP-RX-FP-91-23
Vectibix	Panitumumab	J9303	Panitumumab (Vectibix®)	MP-RX-FP-99-23
Adcetris	Brentuximab	J9042	Brentuximab vedotin (Adcetris®)	MP-RX-FP-01-23
Alimta	Pemetrexed	J9305	Pemetrexed (Alimta®, Pemfexy®)	MP-RX-FP-05-23
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
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
Treanda	Bendamustine	J9033	Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®)	MP-RX-FP-10-23
Vivimusta	Bendamustine	J9056	Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®)	MP-RX-FP-10-23
Abecma	Idecabtagene vicleucel	Q2055	Idecabtagene vicleucel (Abecma®)	MP-RX-FP-111-23
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
Besponsa	Inotuzumab	J9229	Inotuzumab ozogamicin (Besponsa®)	MP-RX-FP-12-23
Blincyto	Blinatumomab	J9039	Blinatumomab (Blyncito®)	MP-RX-FP-14-23
Cyramza	Ramucirumab	J9308	Ramucirumab (Cyramza®)	MP-RX-FP-20-23
Empliciti	Elotuzumab	J9176	Elotuzumab (Empliciti®)	MP-RX-FP-26-23
Erbitux	Cetuximab	J9055	Cetuximab (Erbitux®)	MP-RX-FP-30-23
Halaven	Eribulin	J9179	Eribulin mesylate (Halaven®)	MP-RX-FP-35-23
Imfinzi	Durvalumab	J9173	Durvalumab (Imfinzi®)	MP-RX-FP-39-23
Jevtana	Cabazitaxel	J9043, J9064	Cabazitaxel (Jevtana®)	MP-RX-FP-47-23
Kadcyla	ado-trastuzumab emtansine	J9354	Ado-trastuzumab (Kadcyla®)	MP-RX-FP-48-23
Kyprolis	Carfilzomib	J9047	Carfilzomib (Kyprolis®)	MP-RX-FP-51-23
Libtayo	cemiplimab-rwlc	J9119	Cemiplimab-rwlc (Libtayo®)	MP-RX-FP-54-23
Lunsumio	mosunetuzumab-axgb	J9350	Mosunetuzumab-axgb (Lunsumio®)	MP-RX-FP-55-23
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
Abraxane	Paclitaxel	J9264	Paclitaxel, Protein Bound (Abraxane®)	MP-RX-FP-69-23
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
Perjeta	Pertuzumab	J9306	Pertuzumab (Perjeta®)	MP-RX-FP-71-23
Polivy	Polatuzumab	J9309	Polatuzumab vedotin-piiq (Polivy®)	MP-RX-FP-73-23
Rybrevant	amivantamab-vmjw	J9061	Amivantamab-vmjw (Rybrevant®)	MP-RX-FP-79-23
Tecentriq	Atezolizumab	J9022	Atezolizumab (Tecentriq)	MP-RX-FP-88-23
Trodelvy	Sacituzumab	J9317	Sacituzumab govitecan (Trodelvy®)	MP-RX-FP-94-23
Cosentyx	Secukinumab	C9399; J3490; J3590	Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)]	MP-RX-FP-60-23
Siliq	brodalumab	C9399; J3490; J3590	Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)]	MP-RX-FP-60-23
Taltz	Ixekizumab	C9399; J3490; J3590	Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)]	MP-RX-FP-60-23
Adacel	Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap)	90715	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
Boostrix	Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap)	90715	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
Tetanus-Diphtheria Toxoids Td	Tetanus-Diphtheria Toxoids (Td)	90714	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
Engerix-B	Hepatitis B Vaccine (Recomb)	90756	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
Heplisav-B	Hepatitis B Vaccine Recombinant Adjuvanted	90739	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
PreHevbrio	Hepatitis B Vaccine 3-Antigen Recombinant	90759	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
Recombivax HB	Hepatitis B Vaccine (Recomb)	90746	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
Twinrix	Hepatitis A (Inactivated)-Hepatitis B (Recombinant) Vaccines	90636	Hepatitis B and Tetanus-Containing Vaccines	MP-RX-FP-156-24
Rytelo	Imetelstat	C9399; J3490; J9999	Imetelstat (Rytelo)	MP-RX-FP-157-24
Lymphir	Denileukin diftitox-cxdl	C9399; J3490; J9999	Denileukin diftitox-cxdl (Lymphir)	MP-RX-FP-158-24

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).

MCG

Ver más Políticas

Medical Policy Title	Medical Policy Number
IV Antibiotics	MP-IV-FP-01-23
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
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 07-03-2024
Additional information available – please contact:	liz.roman@mso-pr.com and or sindia.Villegas@mso-pr.com