Priority Health Medicaid physician‑administered Coverage/Prior Auth

Coverage statuses (partial list)

Coverage statuses (partial list) — consolidated excerpts showing per-code and product coverage determinations, including PA (prior authorization), SOS (site-of-service) notes, State Carve Out, Not Covered (often 'Refer to Rx Benefit' or 'Rx Only'), and Benefit Exclusion entries.

J1301 (edaravone): Multiple container types (30 mg/100 mL bag, 60 mg/100 mL bag, vials) — Status = Covered; Notes = PA.

J1413 (ELEVIDYS): Multiple weight-based product SKUs (10.5–69.5+ kg, vial/outer/inner) — Status = State Carve Out; Notes = none.

J1551 (Cutaquig): Multiple vial sizes and pack types — Status = Covered; Notes = PA.

J1555 (Cuvitru): Multiple vial sizes and pack types — Status = Covered; Notes = PA.

J1561 (Gammaked/Gamunex-C): Multiple vial sizes; many J1561 entries show Status = Covered; Notes = PA; SOS — but the associated CPT code 90283 (IgIV) entries are repeatedly listed as Not Covered (operational billing guidance).

J1568 (Octagam): Multiple sizes — Status = Covered; Notes = PA; SOS. Associated 90283 rows show Not Covered for CPT pricing.

J1569 (Gammagard Liquid): Multiple sizes — Status = Covered; Notes = PA; SOS; 90283 entries for the same NDCs often labeled Not Covered.

J1572 (Flebogamma DIF): Multiple sizes — Status = Covered; Notes = PA; SOS; corresponding 90283 rows (CPT IgIV) listed Not Covered.

J1575 (Hyqvia): Multiple pack sizes — Status = Covered; Notes = PA.

J1559 (Hizentra): Multiple presentations — Status = Covered; Notes = PA.

Immune globulin (general): Many product-level J-codes marked Covered with PA and sometimes SOS, while the CPT code 90283 (IgIV) rows for the same product NDCs are shown as Not Covered — providers must bill using the correct J-code and follow PA/SOS guidance.

Factor and coagulation products (examples): Numerous factor VIII/IX and related products (J7205 ELOCTATE; J7210 AFSTYLA; J7207 ADYNOVATE; J7213 IXINITY; J7190/7192/7202/7204/etc.) are consistently marked Not Covered for medical benefit with notes such as 'Refer to Rx Benefit' — indicating these should be billed/reimbursed under the pharmacy benefit or via specialty pharmacy.

Selected covered specialty injectables with PA; SOS: J0225 (Amvuttra) — Covered; Notes = PA; SOS. J2350/J2351 (Ocrevus/OCREVUS ZUNOVO) — Covered; Notes = PA; SOS. J2840 (Kanuma) — Covered; Notes = PA; SOS. J2508 (Elfabio) — Covered; Notes = PA; SOS. J2507 (Krystexxa) — Covered; Notes = PA; SOS. J0875 (Dalbavancin) — Covered; Notes = PA.

Not Covered / Rx Only examples: Many self-administered biologics and NDC-priced products are Not Covered under the medical benefit and annotated 'Rx Only' (e.g., multiple adalimumab biosimilars Q5145/Q5143/Q512?/Q5143 entries, Humira/COPY entries under J0135/J0139, AJOVY J3031, EGRIFTA C9399/J3590, GENOTROPIN/other somatropins J2941, many others).

State Carve Out examples: Multiple vaccines, depot antipsychotic injections, and specialty agents are designated State Carve Out (examples: Q2055 ABECMA, J0401/J0402 Abilify formulations, J1943/J1944 ARISTADA, J3398 LUXTURNA, gene therapies such as J1411 HEMGENIX and J3394 LYFGENIA, buprenorphine ER J0577/J0578, CABENUVA J0741, and others).

Benefit Exclusion examples: Hyaluronan/intra-articular viscosupplements (J7321/J7323/J7326/J7327/J7328 etc.) are marked Benefit Exclusion.

CPT / operational note examples: Use of CPT 90283 (IgIV) appears repeatedly with Status = Not Covered for CPT price rows while corresponding J‑codes for product billing are Covered (PA; SOS) — operational billing guidance: bill the product J‑code and follow PA/SOS; do not bill 90283 for reimbursement pricing when marked Not Covered.

Provider actionable summary: For products marked Covered that include 'PA; SOS' — prior authorization is required and site-of-service rules apply. For entries marked Not Covered with 'Refer to Rx Benefit' or 'Rx Only' — do not bill under the medical benefit; route claims through the pharmacy benefit or specialty pharmacy as indicated. For State Carve Out items — these are outside this medical benefit and follow state program rules. For CPT 90283 and similar CPT-level IgIV rows marked Not Covered — confirm correct J-code submission for medication reimbursement and attach PA documentation as required.

HCPCS/J/CPT code listings and grouped statuses

Covered HCPCS/J-codesHCPCSCovered

J7171	Injection, adamts13, recombinant-krhn (ADZYNMA) - Covered; PA; SOS
Q5121	Infliximab-axxq (AVSOLA) - Covered; PA; SOS
Q5156	Tocilizumab-anoh (AVTOZMA) - Covered; PA; SOS
J9210	Emapalumab-lzsg (GAMIFANT) - Covered; PA; SOS
J2840	Sebelipase alfa (KANUMA) - Covered; PA; SOS
J1301	Edaravone - Covered; PA
J0584	Burosumab (CRYSVITA) - Covered; PA; SOS
J1551	CUTAQUIG immune globulin - Covered; PA
J1555	CUVITRU immune globulin - Covered; PA
J1561	GAMMAKED/GAMUNEX-C immune globulin - Covered; PA; SOS

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Not Covered / Rx Benefit / Refer to RxHCPCSNot Covered

J7207	ADYNOVATE factor VIII - Not Covered; Refer to Rx Benefit
J7210	AFSTYLA factor VIII - Not Covered; Refer to Rx Benefit
J7186	ALPHANATE antihemophilic factor VIII/VWF complex - Not Covered; Refer to Rx Benefit
J7193	ALPHANINE SD factor IX - Not Covered; Refer to Rx Benefit
J7205	ELOCTATE factor VIII Fc fusion - Not Covered; Refer to Rx Benefit
J7204	ESPEROCT factor VIII - Not Covered; Refer to Rx Benefit
J7170	HEMLIBRA emicizumab - Not Covered; Refer to Rx Benefit
J7190	HEMOFIL M factor VIII - Not Covered; Refer to Rx Benefit
J7192	KOGENATE FS factor VIII - Not Covered; Refer to Rx Benefit
J7213	IXINITY factor IX - Not Covered; Refer to Rx Benefit

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Covered (with PA/SOS) and Mixedmixed

J3262	Tocilizumab (ACTEMRA) - Covered; PA; SOS
Q0249	Tocilizumab for hospitalized COVID-19 (Q0249) - Not Covered

Selected J-codes (mixed statuses)HCPCS

J0165	Epinephrine (ADYPHREN) - State Carve Out
J0175	Donanemab (KISUNLA) - Not Covered
J3392	Exagamglogene autotemcel (CASGEVY) - State Carve Out

Hemophilia / Factor products - Not Covered (Refer to Rx Benefit)HCPCSNot Covered

J7186	ALPHANATE - Not Covered; Refer to Rx Benefit
J7193	ALPHANINE SD - Not Covered; Refer to Rx Benefit
J7207	ADYNOVATE - Not Covered; Refer to Rx Benefit
J7210	AFSTYLA - Not Covered; Refer to Rx Benefit
J7205	ELOCTATE - Not Covered; Refer to Rx Benefit
J7204	ESPEROCT - Not Covered; Refer to Rx Benefit
J7195	BENEFIX factor IX - Not Covered; Refer to Rx Benefit
J7213	IXINITY - Not Covered; Refer to Rx Benefit
J7190	HEMOFIL M - Not Covered; Refer to Rx Benefit

Examples - Not Covered / State Carve OutHCPCSNot Covered

J1554	ASCENIV immune globulin - Not Covered
J2060	Lorazepam injections - State Carve Out

Oral prescription drugs - Not Covered (Rx Only)HCPCSNot Covered

J8499

Prescription oral drugs (e.g. atorvastatin) - Not Covered; Rx Only

Mixed coverage and Carve-Out entriesHCPCS

Q2058	Obecabtagene autoleucel (AUCATZYL) - State Carve Out
J1749	Iloprost (AURLUMYN) - Not Covered
Q5121	AVSOLA (infliximab-axxq) - Covered; PA; SOS

Compounded & Immune Globulin examplesHCPCS

J7999	Compounded products (e.g. bevacizumab repack) - Covered; PA (when listed)
90283	90283 CPT for IgIV - Not Covered in many listings; see associated J-codes (J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1599) for non-CPT billing

Buprenorphine extended-release (BRIXADI)HCPCSCovered

J0578	BRIXADI monthly - State Carve Out entries present
J0577	BRIXADI weekly - State Carve Out

Ranibizumab biosimilar / Ocular injectablesHCPCSCovered

Q5124	BYOOVIZ (ranibizumab-nuna) - Covered; PA
J2778	Lucentis (ranibizumab) - Covered; PA

Not Covered examplesHCPCSNot Covered

C9399	Unclassified products listed as Not Covered / Rx Only (multiple entries)
J3590	Unclassified biologics marked Not Covered / Rx Only

Unclassified codes with Not Covered entriesHCPCSNot Covered

J3490	Unclassified drugs - various Not Covered entries
J9999	Not otherwise classified antineoplastics - example Covered entry present

CRYSVITA and Immune Globulin covered entriesHCPCSCovered

J0584	CRYSVITA (burosumab) - Covered; PA; SOS
J1551	CUTAQUIG - Covered; PA
J1555	CUVITRU - Covered; PA

Adalimumab biosimilars - ExamplesHCPCSNot Covered

Q5145	ABRILADA - Not Covered; Rx Only
Q5143	CYLTEZO - Not Covered; Rx Only
Q5140	HULIO - Not Covered; Rx Only

Neurology / Gene & Rare therapiesHCPCS

J1413	ELEVIDYS gene therapy - State Carve Out
J1411	HEMGENIX gene therapy - State Carve Out

Egrifta and related unclassified entries - Not CoveredHCPCSNot Covered

C9399	EGRIFTA SV / WR entries under C9399 - Not Covered; Rx Only
J3590	EGRIFTA entries under J3590 - Not Covered; Rx Only

Immune globulin listings (selected)HCPCSCovered

J1556	BIVIGAM - Listed as Not Covered under J1556 in some rows; other Ig entries covered depending on product
J1569	GAMMAGARD LIQUID - Covered; PA; SOS
J1572	FLEBOGAMMA DIF - Covered; PA; SOS
J1557	GAMMAPLEX - Covered; PA; SOS

Factor / Hemostasis agents - Not CoveredHCPCSNot Covered

J7188	OBIZUR - Not Covered; Refer to Rx Benefit
J7195	BENEFIX - Not Covered; Refer to Rx Benefit

Selected J-codes and statusesHCPCS

J1743	Idursulfase (ELAPRASE) - Covered; PA; SOS
J3060	Taliglucerase alfa (ELELYSO) - Covered; PA; SOS
J9210	GAMIFANT - Covered; PA; SOS

Sample HCPCS mappings / Unclassified examplesHCPCS

J3590	Multiple unclassified biologic entries (review coding guidance for use)
C9399	Multiple unclassified drug/biologic entries (Hospital Outpatient only)

Not Covered / Benefit Exclusion examplesHCPCSNot Covered

J7323	Euflexxa intra-articular hyaluronan - Benefit Exclusion
J7326	Gel-One - Benefit Exclusion

MOUNJARO and similar unclassified product entries - Not CoveredHCPCSNot Covered

J3490	MOUNJARO entries billed to J3490 - Not Covered; Rx Only
C9399	MOUNJARO entries under C9399 - Not Covered; Rx Only

Factor products (not covered under medical; refer to Rx)HCPCSNot Covered

J7182	NOVOEIGHT - Not Covered; Refer to Rx Benefit
J7209	NUWIQ - Not Covered; Refer to Rx Benefit
J7208	JIVI - Not Covered; Refer to Rx Benefit
J7189	NOVOSEVEN RT - Not Covered; Refer to Rx Benefit

Romiplostim - Covered with PAHCPCSCovered

J2802

NPLATE romiplostim - Covered; PA

Mixed: Ocrelizumab & OctagamHCPCS

J2350	OCREVUS ocrelizumab - Covered; PA; SOS
J1568	OCTAGAM - Covered; PA; SOS

Additional Immune Globulin / 90283 mapping notesmixed

J1572	FLEBOGAMMA DIF - Covered; PA; SOS (90283 entries often Not Covered; use product-specific J-codes when applicable)
J1595	Glatiramer acetate (J1595) - Not Covered; Rx Only
J1557	GAMMAPLEX - Covered; PA; SOS
J1599	Referenced for non-CPT IgIV billing guidance

Authorization, billing and provider-facing notes

Prior Authorization

Prior authorization and SOS required for J3262 (Actemra)

J3262 (Actemra) is Covered but requires prior authorization and is subject to site‑of‑service (SOS) restrictions.

J3262, Drug = ACTEMRA 200 MG/10 ML VIAL. J3262, Status = Covered. J3262, Notes = PA; SOS.

Prior Authorization

Prior authorization and SOS required for J7171 (Adzynma)

J7171 (ADZYNMA) is Covered but requires prior authorization and is subject to SOS — obtain authorization before billing.

J7171 entries list Status = Covered and Notes = PA; SOS for multiple kit and vial presentations.

Denial Risk

Denial risk: Q5145 (Abrilada) is Not Covered — Rx Only

Q5145 (Abrilada) is Not Covered for medical billing and is designated Rx Only; claims submitted under medical are at risk of denial.

Q5145, Status = Not Covered. Q5145, Notes = Rx Only.

Prior Authorization

Prior authorization required for J7171

J7171 entries indicate Coverage with administrative controls: prior authorization is required and SOS may apply; secure PA before service.

Multiple J7171 lines show Status = Covered and Notes = PA; SOS.

Prior Authorization

Prior authorization required for J1931, J2277 and J0256

J1931, J2277 and J0256 are listed as Covered but require prior authorization and may have site‑of‑service restrictions; obtain PA prior to administration.

J1931, Status = Covered. J1931, Notes = PA; SOS.
Entries for J2277 and J0256 are noted as Covered with 'PA; SOS'.

Billing Rule

State carve‑out or Rx benefit referral required for some entries

Several products in the list are flagged as State Carve Out or Rx Only; these are not payable under this medical benefit and should be billed per state program or the pharmacy benefit.

Examples: J0165 and J2060 marked State Carve Out; J3031 marked Not Covered with Notes = Rx Only.
When an item is 'Refer to Rx Benefit' or 'Rx Only', route claims to the pharmacy benefit as applicable.

Prior Authorization

Prior authorization and SOS required for infliximab‑axxq (AVSOLA)

AVSOLA (infliximab‑axxq) is Covered but requires prior authorization and may be subject to SOS; obtain PA before infusion.

Q5121 / AVSOLA entries show Status = Covered and Notes = PA; SOS.

Prior Authorization

Prior authorization and SOS required for tocilizumab‑anoh (AVTOZMA)

AVTOZMA (tocilizumab‑anoh) is Covered with a PA requirement and SOS noted; secure prior authorization before administration.

Q5156, Status = Covered. Q5156, Notes = PA; SOS.

Prior Authorization

Prior authorization and SOS required for belimumab (BENLYSTA)

BENLYSTA (belimumab) is Covered but requires prior authorization and may be subject to site‑of‑service restrictions; obtain PA prior to treatment.

J0490, Status = Covered. J0490, Notes = PA; SOS.

Prior Authorization

Prior authorization required for compounded bevacizumab (J7999)

Compounded bevacizumab billed with J7999 is Covered but requires prior authorization; submit PA documentation for compounded product billing.

J7999 entries for compounded bevacizumab show Status = Covered and Notes = PA.

Prior Authorization

Prior authorization required for onabotulinumtoxinA (BOTOX)

OnabotulinumtoxinA (BOTOX, J0585) is Covered and requires prior authorization before service; do not bill without PA.

J0585 entries list Status = Covered and Notes = PA across vial sizes.

Prior Authorization

PA applies to listed biosimilars (e.g., BKEMV, BOMYNTRA)

Certain biosimilars (e.g., Q5152 BKEMV; Q5158 BOMYNTRA) are Covered but may require prior authorization — check specific code notes and obtain PA as indicated.

Q5152, Status = Covered. Q5152, Notes = PA; SOS.
Q5158, Status = Covered (notes indicate coverage).

Prior Authorization

Prior authorization required for BRINEURA and BRIUMVI

BRINEURA (J0567) and BRIUMVI (J2329) are Covered but require prior authorization; J2329 also lists SOS — secure PA before scheduling therapy.

J0567, Status = Covered. J0567, Notes = PA.
J2329, Status = Covered. J2329, Notes = PA; SOS.

Prior Authorization

Prior authorization required for ranibizumab biosimilar (BYOOVIZ)

BYOOVIZ (ranibizumab biosimilar, Q5124) is Covered but requires prior authorization; submit PA to ensure coverage.

Q5124, Status = Covered. Q5124, Notes = PA.

Prior Authorization

PA required for Q5124 (BYOOVIZ)

Q5124 (BYOOVIZ) explicitly notes that prior authorization is required; do not bill without approved PA.

Q5124 entries repeat Notes = PA for vial inner and outer packaging.

Prior Authorization

Obtain prior authorization for many listed biologics (PA/PA; SOS)

Multiple biologics and injectables throughout the list are annotated with 'PA' or 'PA; SOS' (for example, CIMZIA and CINQAIR); verify PA requirements and SOS restrictions before administration.

C9249 / J0717 / J0718 entries (CIMZIA) show Notes = PA; SOS.
J2786 (CINQAIR) and other entries include PA; SOS annotations.

Prior Authorization

PA and site‑of‑service restrictions for CRYSVITA and Cutaquig

J0584 (CRYSVITA) and J1551 (Cutaquig) are Covered but list PA and SOS — obtain prior authorization and confirm site‑of‑service requirements.

J0584, Status = Covered. J0584, Notes = PA; SOS.
J1551, Status = Covered. J1551, Notes = PA.

Prior Authorization

Prior authorization and SOS for J0584 (CRYSVITA)

J0584 (CRYSVITA) is Covered and explicitly notes PA and SOS; secure authorization and confirm site constraints before dosing.

J0584 entry: CRYSVITA 30 MG/ML VIAL — Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization required for CUTAQUIG (J1551) and CUVITRU (J1555)

Immune globulin products J1551 (CUTAQUIG) and J1555 (CUVITRU) are Covered but require prior authorization; submit PA documentation for specific vial sizes.

J1551 entries: Status = Covered. Notes = PA across multiple vial sizes.
J1555 entries: Status = Covered. Notes = PA.

Denial Risk

Denial risk: Q5143 (CYLTEZO) Not Covered — Rx Only

Q5143 (CYLTEZO) adalimumab‑adbm biosimilar is Not Covered and marked Rx Only; medical claims are likely to be denied and should be redirected to the pharmacy benefit.

Q5143 entries show Status = Not Covered. Q5143, Notes = Rx Only.

Prior Authorization

Prior authorization required for J0875 (dalbavancin) and J0586 (Dysport)

J0875 (dalbavancin) and J0586 (Dysport) are Covered but require prior authorization; obtain PA before administration.

J0875, Status = Covered. J0875, Notes = PA.
J0586, Status = Covered. J0586, Notes = PA.

Billing Rule

State Carve Out — J3360 and J1200

J3360 (diazepam) and J1200 (diphenhydramine) are designated State Carve Out and are not handled under this payer's standard medical benefit.

J3360 entries repeatedly list Status = State Carve Out.
J1200 entries are noted as State Carve Out in the listing.

Prior Authorization

Prior authorization required for edaravone (J1301)

Edaravone (J1301) is Covered but requires prior authorization; secure PA prior to administration.

J1301 entries list Status = Covered and Notes = PA across multiple packaging configurations.

Prior Authorization

PA and SOS apply to selected enzyme/replacement therapies

Multiple enzyme and replacement therapies (e.g., ELFABRIO J2508, ELAPRASE J1743, ELELYSO J3060) are Covered but note PA and SOS — obtain PA and confirm site‑of‑service restrictions.

J2508 (ELFABRIO) entries: Status = Covered. Notes = PA; SOS.
Other enzyme therapies in the same excerpt also carry PA; SOS annotations.

Prior Authorization

Prior authorization and SOS required for EMPAVELI (J3490)

EMPAVELI (listed under J3490) is shown as Covered but requires prior authorization and may be subject to SOS; obtain PA before billing.

J3490 entry: EMPAVELI 1,080 MG/20 ML VIAL — Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization and SOS required for ENTYVIO (J3380)

ENTYVIO (J3380) is Covered and requires prior authorization and may be subject to SOS; secure PA before infusion.

J3380 entry: ENTYVIO 300 MG VIAL — Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization and SOS required for EVENITY (J3111)

EVENITY (J3111) is Covered with PA and SOS noted; obtain prior authorization and confirm site requirements.

J3111 entries show Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization and SOS required for EVKEEZA (J1305)

EVKEEZA (J1305) is Covered and notes PA; SOS — secure authorization prior to service.

J1305 entries: Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization required for FLEBOGAMMA DIF (J1572)

FLEBOGAMMA DIF (J1572) immune globulin products are Covered but require prior authorization and may be subject to SOS; obtain PA for each billed vial size.

J1572 listings: Status = Covered. Notes = PA; SOS across multiple vial sizes.
90283 CPT rows for the same products are shown as Not Covered — use the J‑codes and PA process for coverage.

Prior Authorization

Flebogamma (J1572) requires prior authorization (PA) and may have SOS

J1572 (Flebogamma) entries are Covered but repeatedly note PA and SOS; ensure PA is approved and site requirements are met before infusion.

Multiple J1572 lines: Status = Covered. Notes = PA; SOS.

Prior Authorization

PA and SOS apply to selected injectables and IVIG products

Several immune globulin and other injectables (e.g., Gamifant J9210, Flolan J1325, Gammapard/Gammaked) are Covered with PA and SOS where indicated; obtain PA and follow site‑of‑service guidance.

J9210 (GAMIFANT): Status = Covered. Notes = PA; SOS.
J1325 (Flolan): Status = Covered. Notes = PA.
J1561 / J1557 (Gamunex‑C / Gammaplex): Status = Covered. Notes = PA; SOS.

Denial Risk

Denial risk: Not Covered / Rx Only / State Carve Out entries

Multiple entries are explicitly marked Not Covered, Rx Only, or State Carve Out; submit claims accordingly or redirect to the pharmacy benefit to avoid denials.

Examples include many C9399 / J3590 rows marked Not Covered and Notes = Rx Only.
When an item is 'Not Covered' with 'Refer to Rx Benefit', route to the pharmacy benefit.

Prior Authorization

Prior authorization required for many IVIG J‑codes (PA; SOS)

Many IVIG J‑codes (for example J1561, J1557) are Covered but require prior authorization and may carry site‑of‑service restrictions; secure PA prior to infusion and follow billing guidance (use J‑codes rather than CPT 90283 for non‑CPT billing).

J1561 and J1557 entries: Status = Covered. Notes = PA; SOS.
90283 rows for the same products are listed as Not Covered — use the J‑codes and PA workflow.

Prior Authorization

Prior authorization and SOS required for GIVLAARI (J0223) and GLASSIA (J0257)

J0223 (Givlaari) and J0257 (Glassia) are Covered and list PA; SOS — obtain prior authorization and confirm site‑of‑service before treatment.

J0223: Status = Covered. Notes = PA; SOS.
J0257: Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization required for select immune globulins; some products redirect to Rx benefit

Certain immune globulin products (e.g., Hizentra J1559, Hyqvia J1575) are Covered but require prior authorization; for some products billing may be redirected to the pharmacy benefit — verify coverage pathway and obtain PA.

J1559 (Hizentra): Status = Covered. Notes = PA.
J1575 (Hyqvia): Status = Covered. Notes = PA.
Some other injectables in this grouping are Not Covered or Rx Only and should be referred to the Rx benefit.

Denial Risk

Denial risk: Refer Not‑Covered specialty products to the Rx benefit

Multiple specialty biologic and factor products are marked Not Covered with instructions to refer to the Rx benefit; do not bill these under the medical benefit.

Examples: J7170 (Hemlibra), J7190 (Hemofil M), J7187 (Humate‑P) — Status = Not Covered; Notes = Refer to Rx Benefit.

Prior Authorization

Prior authorization required for HYQVIA (J1575)

HYQVIA (J1575) is Covered but requires prior authorization; obtain PA before administration.

J1575 entries: Status = Covered. Notes = PA across multiple pack sizes.

Prior Authorization

PA and SOS apply to multiple biologics (confirm before administration)

Many biologics (e.g., ILARIS, ILUMYA, ILUVIEN, IMAAVY) are Covered with PA and sometimes SOS noted; confirm PA requirements and site constraints prior to service.

J0638 (ILARIS): Status = Covered. Notes = PA; SOS.
J3245 (ILUMYA): Status = Covered. Notes = PA; SOS.
J7313 (ILUVIEN): Status = Covered. Notes = PA.

Prior Authorization

Prior authorization required for KIMYRSA (J2406)

KIMYRSA (J2406) is Covered but requires prior authorization; secure PA before billing.

J2406: KIMYRSA 1,200 MG VIAL — Status = Covered. Notes = PA.

Prior Authorization

Prior authorization required for KORSUVA (J0879)

KORSUVA (J0879) is Covered and requires prior authorization; obtain PA before administration.

J0879 entries: Status = Covered. Notes = PA.

Prior Authorization

Prior authorization and SOS required for KRYSTEXXA (J2507)

KRYSTEXXA (J2507) is Covered but requires prior authorization and may have SOS restrictions; secure PA and verify site‑of‑service rules before therapy.

J2507 entries: Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization and SOS required for LEQVIO (J1306)

LEQVIO (J1306) is Covered but requires prior authorization and notes SOS; obtain PA and confirm site‑of‑service prior to administration.

J1306: LEQVIO 284 MG/1.5 ML SYRINGE — Status = Covered. Notes = PA; SOS.

Prior Authorization

PA required for LUCENTIS and LUMIZYME (PA; SOS)

LUCENTIS (J2778) and LUMIZYME (J0221) are Covered but require prior authorization; LUMIZYME additionally notes SOS — obtain PA and verify site requirements.

J2778 entries: Status = Covered. Notes = PA.
J0221 entry: LUMIZYME — Status = Covered. Notes = PA; SOS.

Prior Authorization

Prior authorization required for ranibizumab (J2778 / LUCENTIS)

J2778 (ranibizumab / LUCENTIS) entries are Covered and list PA — obtain prior authorization before billing.

J2778 lines: Status = Covered. Notes = PA across vial and syringe configurations.

Prior Authorization

PA and SOS may apply for LUMIZYME and NEXVIAZYME

J0221 (LUMIZYME) and J0219 (NEXVIAZYME) are Covered but note PA and SOS — secure PA and confirm allowable site‑of‑service before infusion.

J0221: Status = Covered. Notes = PA; SOS.
J0219 entries indicate Covered with PA; SOS.

Prior Authorization

PA required for romiplostim (J2802 / NPLATE)

Romiplostim (J2802 / NPLATE) is Covered but requires prior authorization; ensure PA is obtained before treatment.

J2802 entries: Status = Covered. Notes = PA for 125, 250, and 500 mcg vials.

Prior Authorization

Romiplostim (NPLATE) — prior authorization required

Romiplostim (NPLATE) is listed Covered with Notes = PA — prior authorization must be in place prior to billing.

J2802 lines: Covered. Notes = PA.

Prior Authorization

PA and SOS apply to OCREVUS and Octagam (confirm PA/SOS)

Ocrelizumab (J2350 / J2351) and Octagam (J1568) are Covered but require prior authorization and may have SOS restrictions; obtain PA and confirm site‑of‑service prior to infusion.

J2350 / J2351: Status = Covered. Notes = PA; SOS.
J1568 (OCTAGAM): Status = Covered. Notes = PA; SOS (90283 rows show Not Covered for CPT aggregation).

Billing Rule

Factor VIII / VIIa products: not covered under medical — refer to Rx benefit

Factor VIII and Factor VIIa products (e.g., J7182, J7189, J7209, J7188) are Not Covered under the medical benefit and should be billed to the pharmacy (Rx) benefit — do not submit these as medical J‑code claims.

J7182, J7189, J7209, J7188 entries: Status = Not Covered. Notes = Refer to Rx Benefit.

Key labels and billing terms

inv-133: State Carve Out — State Carve Out

DefinitionState Carve Out — coverage or billing governed by state-specific programs; items listed as 'State Carve Out' are not paid under this medical benefit and are administered/processed under the state program.

Examples (documented)HEMGENIX (J1411) listings and multiple gene therapy/vaccine entries are marked State Carve Out (see J1411 weight-based listings).

Common manifestationsWhole-product listings (e.g., BRIXADI J0577/J0578), certain CAR-T/gene therapies (Q2058, Q2042), and some psychiatric injectables are designated State Carve Out.

Billing implicationItems marked State Carve Out should not be billed to this payer's medical benefit; follow state program billing instructions.

Source noteMultiple chunks indicate 'Status = State Carve Out' for listed codes (e.g., chunks 180–183, 224, 234).

inv-134: Rx Only — Rx Only — drug is subject to prescription drug benefit rather than covered as a physician‑administered/inpatient drug

DefinitionRx Only — drug is subject to the pharmacy (prescription) benefit rather than the physician‑administered/inpatient medical benefit.

Examples (documented)Multiple adalimumab biosimilars and biologic pen/syringe SKUs are marked 'Rx Only' or routed to pharmacy (e.g., Q5145, Q5143, J0135/J0139 listings).

Provider actionDo not bill these items to the medical outpatient/provider-administered drug benefit; submit under the pharmacy claim system per payer instructions.

Indicator in listEntries use notes 'Rx Only' or 'Refer to Rx Benefit' to denote pharmacy benefit routing (chunks 3, 22, 59, 254).

inv-135: PA; SOS — PA; SOS — subject to prior authorization and state or payer-specific special authorization/status (SOS) requirements

DefinitionPA; SOS — Prior Authorization required; Site‑of‑Service (SOS) notes indicate restrictions or special authorization/status tied to administration setting.

Examples (documented)Actemra (J3262), Cutaquig (J1551), Entyvio (J3380), and many IVIG/J-code entries list 'PA; SOS' in notes.

ImplicationCoverage requires payer approval before administration and may require administration in specific settings as noted by SOS.

Provider stepObtain prior authorization and confirm permitted site of service per the 'PA; SOS' note before scheduling treatment.

inv-136: 90283 (IgIV billing note) — 90283 is used for Immune Globulin (IgIV), human, for intravenous use (code price per 500 mg); additional non-CPT billing codes referenced

Primary code guidance90283 is the CPT code for Immune Globulin (IgIV), human, for intravenous use; code price is per 500 mg.

CPT vs J-code noteUse 90283 for CPT billing requirements ONLY — specific product J‑codes (e.g., J1561, J1572, J1568) are listed for non‑CPT billing of IVIG products.

Status in document90283 rows are repeatedly shown as 'Not Covered' while corresponding product J‑codes may be Covered with PA; SOS (see chunks 35, 126, 145).

Practical effectDo not aggregate IVIG reimbursement under 90283 when a product-specific J‑code is required; follow the J‑code billing guidance in the listing.

inv-137: Refer to Rx Benefit — 'Refer to Rx Benefit' indicates the item is not payable under this outpatient/provider-administered drug benefit and should be processed ...

DefinitionRefer to Rx Benefit — indicates the item is not payable under this outpatient/provider-administered medical benefit and should be processed under the pharmacy (prescription) benefit.

Examples (documented)Multiple factor VIII and factor products (e.g., J7207 ADYNOVATE, J7210 AFSTYLA, J7182 NOVOEIGHT) are annotated 'Refer to Rx Benefit'.

Billing actionProviders should route claims for listed products to the pharmacy benefit or follow payer-specific pharmacy processing instructions rather than submitting to medical outpatient claims.

Source noteDocument shows 'Notes = Refer to Rx Benefit' for many entries (chunks 18, 109, 252–257).

inv-138: PA; SOS — 'PA; SOS' denotes prior authorization required and likely specialty or site-of-service considerations

DefinitionPA; SOS — 'PA; SOS' denotes prior authorization required and may include site‑of‑service limitations or specialty authorization requirements.

Examples (documented)BYOOVIZ (Q5124), ACTEMRA (J3262), and CRYSVITA (J0584) entries include 'PA' or 'PA; SOS' notes requiring approval and sometimes site restrictions.

Provider requirementSubmit a prior authorization request and document the intended site of service when noted to secure coverage.

Consequence of noncomplianceClaims without required PA or administered outside approved SOS may be denied or redirected to alternate benefit paths.

inv-139: State Carve Out — 'State Carve Out' indicates coverage or billing is governed by state-specific programs or carve-outs rather than this payer policy

DefinitionState Carve Out — coverage or payment is managed under a state-specific program; items listed are excluded from this payer's medical benefit.

Examples (documented)Lorazepam (J2060), CAR‑T/gene therapies (Q2058, Q2042), and certain injectables (e.g., BRIXADI J0577/J0578) are shown as State Carve Out.

Billing implicationDo not bill these items to the payer's standard medical benefit; follow state program billing instructions or alternate contracts.

Labeling in listEntries include 'Status = State Carve Out' adjacent to the code and drug description (e.g., chunks 37, 39, 54, 224).

inv-140: State Carve Out — Indicates the drug/service is excluded from this policy's coverage because the state has carved it out of the plan's medical benefit in t...

DefinitionStatus = State Carve Out — indicates the item's payment or administration may be managed by a state program and is not covered under this payer's outpatient medical listing.

Examples (documented)Several high-cost gene therapies and specialty products (HEMGENIX J1411, KYMRIAH Q2042) are shown as State Carve Out; epinephrine and lorazepam variations also listed.

Operational noteClaims for State Carve Out items should be escalated to the appropriate state program or third‑party vendor as instructed by the payer.

inv-141: PA — Prior Authorization required (as noted in multiple covered entries)

DefinitionPA — Prior Authorization required by the payer before coverage is approved.

Examples (documented)Ranibizumab biosimilars (Q5124/Q5128), CRYSVITA (J0584), and romiplostim (J2802) are listed as Covered with PA required.

Provider actionSubmit required documentation for PA; treatment without approval may result in claim denial.

Associated notesPA entries often appear with SOS (PA; SOS) where site constraints apply (see J3262, J2350).

inv-142: Rx Only — Drug is prescription-only; entry may be routed to pharmacy benefit or excluded from medical reimbursement

DefinitionRx Only — Drug is prescription-only and may be routed to the pharmacy benefit; entries marked Rx Only are typically not covered under the medical benefit.

Examples (documented)Abrilada (Q5145), AJOVY (J3031), and multiple adalimumab/adalimumab biosimilars have 'Notes = Rx Only' indicating pharmacy routing.

Processing implicationBill these items through pharmacy claims or refer to the Rx Benefit per payer instructions rather than submitting as a J‑code medical claim.

inv-143: State Carve Out — Indicates that the item's payment or administration may be managed under a state-specific program or carve-out (as presented alongside mu...

DefinitionState Carve Out — payment or administration may be managed under a state-specific program or carve-out; items are not paid under this listing.

Examples (documented)Obecat/other CAR‑T/gene therapies (Q2058, Q2042), lorazepam (J2060) and other items show 'Status = State Carve Out'.

Action for providersConfirm whether the item should be billed to a state program or alternate contract; do not submit to the standard medical drug list for these items.

inv-144: PA — Prior Authorization — the payer requires approval before coverage (noted in many rows, e.g., Q5124, J2786)

DefinitionRx Only / Not Covered — denotes products identified as not covered under this medical benefit and instead directed to the pharmacy benefit (Rx Only) or explicitly Not Covered.

Examples (documented)Multiple adalimumab biosimilars (Q5143/Q5145), fremanezumab (J3031), and other unclassified pen/syringe products are shown as Not Covered with 'Rx Only' notes.

ImplicationThese items are denial risks for medical claims; providers should route to pharmacy benefit or seek guidance before billing medically.

inv-145: SOS — Site Of Service restriction or note (appears with some PA notes, e.g., C9249, J2786, J0584)

DefinitionSOS — Site Of Service note indicating administration setting considerations; may appear with PA (PA; SOS).

Examples (documented)CIMZIA (C9249/J0717), CRYSVITA (J0584), Gamunex/Gammaked (J1561) entries include SOS or PA; SOS notes.

Provider implicationConfirm approved site(s) of administration when SOS is listed to ensure claim eligibility and compliance.

inv-146: Rx Only / Not Covered — Denotes products the payer identifies as not covered under this benefit (often directing to pharmacy/Rx benefit)

DefinitionRx Only / Not Covered — Denotes products the payer identifies as not covered under this benefit; often directs providers to the pharmacy benefit.

Examples (documented)Egrifta (C9399/J3590), ENS/Immunomodulatory autoinjectors, and many adalimumab/etanercept entries are marked Not Covered and Rx Only.

Billing guidanceDo not submit these items on medical claims; process under the prescription drug benefit where applicable.

inv-147: prior authorization required — PA

Most actionable guidance90283 billing guidance — Use CPT 90283 for CPT billing requirements ONLY; specific IVIG products must be billed using product J‑codes (e.g., J1561, J1572, J1568) which may be Covered with PA; 90283 rows in this list are shown as Not Covered.

Explanation90283 is defined as Immune Globulin (IgIV), human, per 500 mg, but document repeatedly flags 90283 as Not Covered while product J‑codes are used for non‑CPT billing.

Examples (documented)Flebogamma (J1572), Gamunex/Gammaked (J1561), Octagam (J1568) are Covered with PA; the corresponding 90283 entries are Not Covered (chunks 126–146, 260–261).

Action for coding/billing teamsWhen administering IVIG, bill using the specific J‑code for the product per the listing; do not rely on 90283 aggregation for reimbursement unless payer instructs otherwise.

inv-148: prescription drug; not payable under this billing context — Rx Only

DefinitionRefer to Rx Benefit / Rx Only — indicates the product is processed under the pharmacy benefit; medical claims will be Not Covered or redirected.

Examples (documented)Factor VIII products (J7207, J7210, J7182, J7209), ELOCTATE (J7205), and multiple hemophilia agents show 'Notes = Refer to Rx Benefit'.

Provider/billing actionSubmit claims to the pharmacy benefit or seek payer instruction; do not submit to the medical benefit when 'Refer to Rx Benefit' is noted.

inv-149: coverage handled outside this payer's standard benefit (state-specific carve-out) — State Carve Out

DefinitionState Carve Out — reimbursement handled outside this payer's standard medical benefit; items are managed under state-specific programs or carve-outs.

Examples (documented)CAR‑T and gene therapies (HEMGENIX J1411, KYMRIAH Q2042), and certain hospital‑administered vaccines are listed as State Carve Out.

ImplicationProviders must confirm state program billing procedures; claims submitted to this medical list for State Carve Out items will not be paid.

inv-150: C9399 — Unclassified drugs or biologicals (This code should only be used for drugs and biologicals that are approved by the FDA on or after Janua...)

C9399 definitionC9399 — Unclassified drugs or biologicals (hospital outpatient use only); code is used for products not assigned a specific HCPCS/J‑code and is frequently shown as Not Covered/Rx Only in this document.

Related J-codeJ3590 — Unclassified biologics, used similarly for unclassified biologic products and often flagged Not Covered/Rx Only.

Document noteMultiple C9399/J3590 entries (e.g., ACTEMRA pen, ENTYVIO pen, KEVZARA) are annotated 'Not Covered' and 'Rx Only' (chunks 4, 114, 216).

inv-151: State Carve Out — State Carve Out

DefinitionState Carve Out — listed items whose reimbursement is subject to a state program carve‑out (not paid under this medical benefit).

Representative entries90283 listings show many State Carve Out or Not Covered flags for IVIG products while product J‑codes indicate coverage status; gene therapies and certain specialty products are also State Carve Out.

ActionConfirm state program routing; do not bill the payer's standard outpatient medical channel for these items.

inv-152: PA; SOS — PA; SOS indicates the drug is covered but requires prior authorization and is subject to site-of-service considerations

PA; SOS definitionPA; SOS — indicates the drug is Covered but requires prior authorization and may have site‑of‑service restrictions (obtain PA and confirm SOS before administration).

Examples (documented)Flebogamma (J1572), Gamunex/Gammaked (J1561), Octagam (J1568), and Ocrevus (J2350/J2351) are shown as Covered with 'PA; SOS'.

Provider requirementSubmit PA requests including documentation of intended site of service; claims lacking PA or outside allowed SOS may be denied.

inv-153: Rx Only / Refer to Rx Benefit — Rx Only / Refer to Rx Benefit indicates the product is covered (or not) under the pharmacy benefit rather than medical benefit

DefinitionImmune Globulin (IgIV) — 90283 is the CPT aggregated code for IgIV priced per 500 mg; product-specific J‑codes should be used for actual IVIG products and may have different coverage statuses.

Key billing noteUse CPT 90283 for CPT billing requirements ONLY; see J‑codes (e.g., J1561, J1572, J1568) for non‑CPT billing of specific IVIG products.

Coverage nuance90283 rows are often Not Covered while corresponding J‑codes for the same products are Covered with PA and SOS — follow product‑specific J‑code guidance.

inv-154: Immune Globulin (IgIV), human, for intravenous use (Code Price is per 500 mg) — note: Use 90283 for CPT billing requirements ONLY; see listed J-codes for non-CPT billing

Status designationsStatus labels in the listing include: 'Covered' (often with 'PA' or 'PA; SOS'), 'Not Covered' (often with 'Rx Only' or 'Refer to Rx Benefit'), 'State Carve Out', and 'Benefit Exclusion'.

Usage guidanceInterpret each line-item by its code-level notes: follow PA, SOS, State Carve Out, or Refer to Rx Benefit instructions as stated in the listing.

Most common combinationsCommon pairings: 'Covered' + 'PA' or 'PA; SOS' for many J‑codes; 'Not Covered' + 'Rx Only' or 'Refer to Rx Benefit' for many factor and biologic products; 'State Carve Out' for high-cost gene/CAR‑T therapies.

inv-155: Status designations indicating coverage exclusion or that drug is prescription-only per entry notes.

Common status labelsState Carve Out, Rx Only, PA, SOS, Not Covered, Benefit Exclusion — these denote payer handling and billing pathway for listed drugs.

Typical implicationsState Carve Out = billed to state program; Rx Only/Refer to Rx Benefit = billed to pharmacy; PA/PA; SOS = require prior authorization and possibly specific site of service; Not Covered = denial risk under this benefit.

Document prevalenceThe list shows many entries using these status designations across J/Q/C/CPT codes (see multiple chunks cited throughout the document).

OpenPayer

Medicaid Medical Drug List — physician-administered drugs reimbursement and coverage statuses

Coverage determinations and examples

HCPCS/J/CPT code listings and grouped statuses

Authorization, billing and provider-facing notes

Key labels and billing terms