Currentpriority healthPolicy N/A

Priority Health medical drug coverage list (partial)

Governs medical (HCPCS/CPT) drug coverage levels, notes and restrictions for Priority Health Commercial and MyPriority plans; affects providers billing injectable and medical-administered drugs to these plans.

Policy Summary

Payerpriority health

PolicyPriority Health medical drug coverage list (partial)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line indicates PA before administering or billing the drug.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20+Distinct entries shown

multipleRequire PA/SOS/CA flags

severalNot Covered items

vaccinesPreventive vaccine codes

Coverage determinations and restrictions

inv-01: coverage lines (partial)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage levels and notes provided per HCPCS/CPT drug line indicate whether an item is Covered (with designation), Not Covered, Preferred Specialty, Non‑Specialty, or requires Prior Authorization; some lines include site‑of‑service or covered‑alternative guidance.

J0716 (ANASCORP) — Coverage Level: Preferred Specialty; Notes: per vial

Q5149 (aflibercept-abzv / enzeevu) — Coverage Level: Not Covered; Notes: CA (covered alternatives listed)

J0895 (deferoxamine) — Coverage Level: Non‑Preferred; Notes: PA required with ICD‑10 exceptions listed

J1448 (trilaciclib / COSELA) — Coverage Level: Preferred Specialty; Notes: PA required

inv-02: First‑generation cephalosporins (cefazolin)

Covered when the cefazolin line items (first‑generation cephalosporins) are billed as listed — these are assigned Non‑Specialty coverage across multiple J‑codes and vial configurations.

J0687, J0688, J0689, J0690 (cefazolin variants) — Coverage Level: Non‑Specialty; Notes: multiple vial sizes/configurations listed

J0690 — multiple packaging SKUs all explicitly listed as Coverage Level = Non‑Specialty

inv-03: Not covered cephalosporins / combinations

Not covered when billed as the listed higher‑generation cephalosporins or combination agents; many Not Covered entries include Covered Alternative(s) and Site‑of‑Service notes.

J0714 (AVYCAZ — ceftazidime/avibactam) — Coverage Level: Not Covered; Notes: CA (Covered Alternatives: cefazolin, ceftriaxone, cefepime, vancomycin, imipenem-cilastatin, meropenem, piperacillin‑tazobactam); Site of Service

J0681 (ZEVTERA), J0695 (ZERBAXA), J0712 (ceftaroline) — Coverage Level: Not Covered; Notes: CA (Covered Alternatives: cefazolin, ceftriaxone, cefepime, vancomycin, imipenem‑cilastatin, meropenem, piperacillin‑tazobactam); Site of Service

inv-04: Carbapenems and piperacillin‑tazobactam

Carbapenems and extended‑spectrum penicillins have mixed coverage: some products are Not Covered (often with CA/SOS) while others are Non‑Specialty or Preferred Specialty.

Examples

J0742 (RECARBRIO — imipenem/cilastatin/relebactam) — Coverage Level: Not Covered; Notes: Site of Service
J2183/J2184/J2185 (meropenem variants) — Coverage Level: Preferred Specialty (some manufacturer‑specific codes); Notes: preferred specialty entries without CA
J2186 (VABOMERE — meropenem/vaborbactam) — Coverage Level: Not Covered; Notes: CA (covered alternatives listed); Site of Service

inv-05: Selected drug coverage entries

Representative coverage stances and restrictions for selected drug lines in this segment.

ANY of the following

J0122 (XERAVA / eravacycline) — Coverage Level: Not Covered; Notes: Site of Service
J0875 (dalbavancin / DALVANCE) — Coverage Level: Non‑Preferred or Not Covered depending on entry; Notes: PA; Site of Service; CA mentioned for some entries
J0458 (EMBLAVEO) — Coverage Level: Not Covered; Notes: Site of Service

inv-06: Preventive coverage examples

Preventive and quantity‑limited items appear in the list; preventive monoclonal antibodies require PA and certain products have ICD‑10–based PA exceptions.

J0738/J0752 (lenacapavir / YEZTUGO) — Coverage Level: Covered for PrEP; Notes: No PA required if billed with ICD‑10 Z29.81; Quantity limits apply (examples: 2 injections per year for J0738; 4 tablets per year for J0752)

90380/90381 (BEYFORTUS) — Coverage Level: Preventive; Notes: PA required

inv-07: Excerpted coverage nodes (JSON-encoded CriteriaNode)

Selected coverage levels and restrictions from the excerpted nodes; entries reference ADL, PA, and site‑of‑service flags where applicable.

J0750 / J0751 (emtricitabine/tenofovir variants) — Coverage Level: Refer to Approved Drug List (ADL); Notes: for HIV pre‑exposure prophylaxis only

J1570 (ganciclovir sodium) — Coverage Level: Non‑Specialty; Notes: PA/SOS/other flags may apply

J0691 (lefamulin) — Coverage Level: Not Covered; Notes: NDCs inactive as of 1/3/2024

C9257 (AVASTIN / bevacizumab) — Coverage Level: Preferred Specialty; Notes: PA generally required but No PA for specified ICD‑10 codes

inv-08: Selected coverage examples

Coverage examples illustrate use of Covered Alternative (CA) notes, PA, site‑of‑service and ICD‑10 exceptions across oncology and biologic products.

ANY of the following

J9035 / J9054 / J9072 — Multiple oncology drug codes listed as Not Covered with Covered Alternatives specified
J9144 (daratumumab formulation) — Coverage Level: Preferred Specialty; Notes: PA; No PA required for specified ICD‑10 diagnoses

inv-09: Per-J-code coverage entries (examples)

Per‑J‑code examples showing Preferred Specialty, Non‑Specialty, Not Covered statuses and common notes (PA, SOS, CA, quantity limits).

J9172 (docetaxel docivyx) — Coverage Level: Not Covered; Notes: CA alternative J9171; Site of Service

J9173 (durvalumab / IMFINZI) — Coverage Level: Preferred Specialty; Notes: PA; Site of Service

J9183 (INLEXZO) — Coverage Level: Non‑Preferred; Notes: PA; Quantity Limit

J9249 / J9311 — Not Covered examples with Covered Alternatives and Site of Service notes

inv-10: Selected coverage entries

Selected entries showing Not Covered classification with listed alternatives, Non‑Specialty listings with PA/SOS flags, and manufacturer‑specific notes.

J9312 (rituximab) — Coverage Level: Not Covered; Notes: CA (biosimilar alternatives Q5123/Q5119/Q5115); Site of Service

J9314 (pemetrexed) — Coverage Level: Non‑Specialty; Notes: PA; Site of Service; CC flags present

J9355 (trastuzumab original) — Coverage Level: Not Covered; Notes: CA (biosimilar alternatives listed); Site of Service

inv-11: Cellular/Gene Therapy

Cellular and gene therapy codes are covered with criteria and routinely require prior authorization and site‑of‑service review.

Q2041 / Q2042 / Q2053 etc. — Coverage Level: Cellular/Gene Therapy; Notes: PA required; Site of Service; billed per therapeutic dose

inv-12: Observed coverage entries

Observed coverage entries highlight ADL/C9399/J3590 usage, preferred specialty listings, and PA/SOS flags for immune globulins and other high‑cost items.

C9399 / J3590 — Coverage Level: Refer to Approved Drug List (ADL) or Preferred Specialty; Notes: used for unclassified drugs/biologics and may require PA

90284 / J1459 / other immune globulin codes — Coverage Level: Preferred Specialty; Notes: PA; Site of Service where specified

inv-13: Not covered with alternatives

Multiple Not Covered immune globulin entries list Covered Alternatives and site‑of‑service flags.

J1552 / J1553 / J1599 / J1554 / J1566 / others — Coverage Level: Not Covered (for specific products); Notes: CA (Covered Alternatives: J1459 Privigen, J1557 Gammaplex, J1561 Gamunex‑C, etc.); Site of Service

inv-14: Vaccine coverage

COVID‑19 and other vaccines are labeled Preventive where indicated.

91304 / 91319 / 91320 / 91321 / 91322 / 91323 — Coverage Level: Preventive; Notes: listed as Preventive COVID‑19 vaccines

inv-15: Coverage level entries

Coverage level labels and notes across selected entries; items include Preferred Specialty, Non‑Specialty, Not Covered, and explicit flags in Notes & Restrictions.

ANY of the following

J2791 (Rhophylac) — Coverage Level: Non‑Specialty; Notes: PA/SOS flags referenced
J0585 / J0586 (botulinum toxin variants) — Coverage Level: Preferred / Preferred Specialty; Notes: PA required for certain uses
J1920 / J1921 (labetalol injections) — Coverage Level: Non‑Specialty; Notes: J1921 not therapeutically equivalent and NDCs inactive as noted

inv-16: Selected code coverage entries

Selected code entries and notable restrictions including preferred specialty designations and Not Covered biosimilars with covered alternatives.

J1920 / J1921 (labetalol) — Coverage Level: Non‑Specialty; Notes: multiple presentations listed; J1921 NDCs inactive as of 3/18/2026

J2506 (pegfilgrastim / Neulasta) — Coverage Level: Preferred Specialty

Q5111 / Q5120 / Q5122 / Q5125 etc. (pegfilgrastim biosimilars) — Coverage Level: Not Covered; Notes: CA to J2506; Site of Service

inv-17: High‑complexity therapy coverage notes

Cellular/gene therapy and other high‑complexity agents require prior authorization and site‑of‑service review.

J1411 / J1412 / J1413 / other J/Q cellular/gene therapy codes — Coverage Level: Cellular/Gene Therapy; Notes: PA; Site of Service

inv-18: Coverage stances in this segment

Many specialty injectables and factor products reference the Approved Drug List (ADL) and include PA/SOS flags.

Multiple factor and specialty injectable codes (e.g., J7179, J7180, J7192, J1305) — Coverage Level: Refer to ADL or Preferred Specialty depending on product; Notes: PA; Site of Service; ADL references common

inv-19: Explicit coverage examples

Explicit examples show Preferred Specialty, Not Covered, and ADL references with accompanying notes.

ANY of the following

J3590 — Coverage Level: Preferred Specialty or Refer to ADL in specific listings; Notes: PA; Site of Service
J1305 (EVKEEZA) — Coverage Level: Preferred Specialty; Notes: PA; Site of Service
J1437 (MONOFERRIC) — Coverage Level: Non‑Preferred

inv-20: Labetalol (J1920/J1921)

Labetalol presentations are consistently listed as Non‑Specialty; one manufacturer variant is noted as not therapeutically equivalent and has inactive NDCs.

J1920 — Coverage Level: Non‑Specialty; Notes: multiple presentations listed as Non‑Specialty

J1921 (Hikma) — Coverage Level: Non‑Specialty; Notes: not therapeutically equivalent to J1920; All NDCs inactive as of 3/18/2026

inv-21: Pulmonary hypertension agents (selected)

Pulmonary vasodilators (treprostinil) and epoprostenol are specialty products with PA and site‑of‑service restrictions.

J3285 (treprostinil / REMODULIN) — Coverage Level: Preferred Specialty; Notes: PA; Site of Service

J1325 (epoprostenol) — Coverage Level: Non‑Preferred; Notes: PA; Site of Service

inv-22: Clevidipine and certain agents not covered

Certain agents are explicitly Not Covered or have site‑of‑service restrictions.

J0759 (CLEVIPREX / clevidipine) — Coverage Level: Not Covered; Notes: Site of Service

J1941 (FUROSCIX) — Coverage Level: Not Covered; Notes: Site of Service

inv-23: ADL / Refer to Approved Drug List

Several unclassified or specialty‑coded products reference the Approved Drug List (ADL) for coverage determination.

C9399 / J3590 / J3490 / other unclassified entries — Coverage Level: Refer to Approved Drug List (ADL) or as specified; Notes: ADL determines coverage/coding guidance

inv-24: Cellular/Gene Therapy coverage with authorization

Cellular and gene therapies require prior authorization and site‑of‑service review; coverage is subject to criteria.

Multiple J/Q cellular/gene therapy codes (e.g., J3399, J3401, Q2041) — Coverage Level: Cellular/Gene Therapy; Notes: PA; Cellular/Gene Therapy designation; Site of Service

inv-25: Not covered / site-of-service restrictions

Certain items are Not Covered except in constrained circumstances (e.g., billed with anesthesia); site‑of‑service restrictions apply.

J3490 (ketamine injection / KETALAR) — Coverage Level: Not Covered as standalone; Notes: Covered only when billed with an anesthesia service for a covered procedure; otherwise Not Covered; Site of Service

J0138 (COMBOGESIC IV acetaminophen+ibuprofen) — Coverage Level: Not Covered; Notes: Site of Service restriction

inv-26: Inhalation product coverage guidance

Inhalation products and cartridges reference the ADL and specific J‑codes; some cartridge SKUs refer to J3535 and ADL for coverage.

TYVASO cartridge SKUs (J3535/J7686 references) — Coverage Level: Refer to Approved Drug List (ADL); Notes: J3535 referenced in Notes & Restrictions; some entries list Preferred Specialty for specific inhalation product codes

inv-27: excerpt coverage items

Selected coverage determinations and restrictions observed in the excerpt: Not Covered designations commonly include Covered Alternatives and site‑of‑service notes.

ANY of the following

J3490 (ketamine) — Not Covered; Notes: Site of Service; CC (covered only with anesthesia)
J2428 (ERZOFRI) — Not Covered; Notes: CA (Covered Alternatives: J2427, J2426); Site of Service
J2561 (SEZABY / phenobarbital formulation) — Not Covered; Notes: CA (Covered Alternative: J2560); Site of Service
J0138 (COMBOGESIC IV) — Not Covered; Notes: Site of Service restriction

inv-28: Extracted coverage entries

Extracted entries showing Not Covered items with covered alternatives, Site‑of‑Service notes, and PA requirements for certain codes.

J2561 — Coverage Level: Not Covered; Notes: Covered Alternative J2560; Site of Service

J3490 (ketamine) — Coverage Level: Not Covered as standalone; Notes: covered only with anesthesia service

J0138 — Coverage Level: Not Covered; Notes: Site of Service restriction

J3032 — Coverage Level: Non‑Preferred; Notes: PA required

HCPCS/CPT code groups and billing notes

sample HCPCS/CPT codes presentHCPCSCovered

J0716	Injection, centruroides immune f(ab)2, up to 120 mg
J0895	Injection, deferoxamine mesylate, 500 mg
J0690	Injection, cefazolin sodium, 500 mg

examples listed as Not CoveredHCPCSNot Covered

Q5149	Injection, aflibercept-abzv (enzeevu), biosimilar, 1 mg
Q5150	Injection, aflibercept-mrbb (ahzantive), biosimilar, 1 mg

cefazolin / 1st generation cephalosporinsHCPCS | mixedCovered

J0687	Injection, cefazolin sodium, 500 mg
J0690	Injection, cefazolin sodium, 500 mg

CarbapenemsHCPCS

J2183	Injection, meropenem (wg critical care), 100 mg
J2185	Injection, meropenem, 100 mg
J2186	Injection, meropenem and vaborbactam

Echinocandin antifungalsHCPCS

J0349	Injection, rezafungin, 1 mg
J2248	Injection, micafungin sodium, 1 mg

Extended‑spectrum penicillins (piperacillin‑tazobactam)HCPCS | CPTCovered

J2543	Injection, piperacillin sodium/tazobactam sodium, 1 g/0.125 g
C9399	Unclassified drugs or biologicals (often used for piperacillin‑tazobactam hospital outpatient)

Extended-spectrum penicillinsHCPCS | CPT

J2543	Injection, piperacillin sodium/tazobactam, 1 g/0.125 g
C9399	Unclassified drugs or biologicals (hospital outpatient use only)

Glycopeptide antibioticsHCPCS | CPT

J3095	Injection, telavancin, 10 mg
J3374	Injection, vancomycin hydrochloride (mylan), 10 mg
J3375	Injection, vancomycin hydrochloride (xellia), 10 mg

Monoclonal antibodies (RSV)HCPCS | CPT

90378	Respiratory syncytial virus monoclonal antibody, intramuscular, 50 mg
90380	BEYFORTUS, RSV monoclonal antibody, seasonal dose 0.5 mL

Selected J-codes and descriptionsHCPCS | CPTCovered

J0750	Emtricitabine 200mg and tenofovir disoproxil fumarate 300mg, oral, for HIV pre-exposure prophylaxis
J0751	Emtricitabine 200mg and tenofovir alafenamide 25mg, oral, for HIV pre-exposure prophylaxis
J1570	Injection, ganciclovir sodium, 500 mg

Not Covered / Unclassified examplesHCPCS | CPTNot Covered

J0691	Injection, lefamulin, 1 mg — Coverage Level = Not Covered
J3490	Unclassified drugs — examples in excerpt marked Not Covered or Site of Service
J0699	Injection, cefiderocol, 10 mg — Coverage Level = Not Covered

Sample J-codes and descriptions from this excerptHCPCS/CPT

J9022	Injection, atezolizumab, 10 mg
J9023	Injection, avelumab, 10 mg
J9024	Injection, atezolizumab 5 mg and hyaluronidase

Additional J-codes listedHCPCS/CPT

J9144	Injection, daratumumab, 10 mg and hyaluronidase-fihj (DARZALEX FASPRO)
J9145	Injection, daratumumab, 10 mg (DARZALEX)
J9171	Injection, docetaxel, 1 mg

Sample J-codes and statusesHCPCS

J9172	Injection, docetaxel (docivyx) — Not Covered
J9173	Injection, durvalumab, 10 mg — Preferred Specialty; PA; Site of Service

Immunotherapy/oncology examplesHCPCSCovered

J9264	Injection, paclitaxel protein-bound particles (ABRAXANE), 1 mg
J9271	Injection, pembrolizumab (KEYTRUDA), 1 mg — Preferred Specialty; PA; Site of Service

Sample drug HCPCS codes and descriptionsHCPCS

J9312	Injection, rituximab, 10 mg
J9314	Injection, pemetrexed (teva), 10 mg

Cellular/Gene Therapy codesHCPCS

Q2041	Axicabtagene ciloleucel (YESCARTA), per therapeutic dose
Q2042	Tisagenlecleucel (KYMRIAH), per therapeutic dose

Unclassified drug/biologic billing codesHCPCS | mixed

C9399	Unclassified drugs or biologicals (hospital outpatient use only)
J3590	Unclassified biologics (refer to Approved Drug List)

Representative HCPCS/CPT codes for immune globulins and vaccinesHCPCS | CPT | mixedCovered

90284	Immune globulin (SCIg), human, for subcutaneous infusions, 100 mg
J1459	PRIVIGEN (IVIG) 500 mg
91304	NUVAXOVID 2025-2026 (COVID-19) vaccine, recombinant nanoparticle

Selected HCPCS/J codes in excerptHCPCS | mixedCovered

91304	NUVAXOVID 2025-2026 (recombinant spike protein nanoparticle) — Preventive
91319	COMIRNATY 2025-2026 (5-11Y) — Preventive
J2791	Injection, Rho(D) immune globulin (Rhophylac), 100 IU — Non‑Specialty
J0585	onabotulinumtoxinA, 1 unit — Preferred
J0586	abobotulinumtoxinA, 5 units — Preferred Specialty
J0475	baclofen, 10 mg (intrathecal) — Preferred Specialty
J0476	baclofen, 50 mcg (intrathecal trial) — Non‑Specialty
J1920	labetalol hydrochloride, 5 mg injection — Non‑Specialty
J1921	labetalol 10 mg/2 ml — Non‑Specialty
J2710	neostigmine methylsulfate up to 0.5 mg — Non‑Specialty

1–10 of 11

1/2

Labetalol injectionsHCPCS

J1920	Injection, labetalol hydrochloride, 5 mg
J1921	Injection, labetalol hydrochloride (Hikma), not therapeutically equivalent to J1920

Pegfilgrastim products (originator and biosimilars)HCPCS

J2506	Injection, pegfilgrastim (Neulasta), 0.5 mg
Q5111	Injection, pegfilgrastim-cbqv (Udenyca), biosimilar, 0.5 mg — Not Covered

Selected HCPCS/CPT codes in this segmentHCPCS | CPT

J7179	Injection, Von Willebrand factor (Vonvendi), 1 IU VWF:RCo
J7180	Injection, factor XIII (Corifact), per IU
J7192	Factor VIII (antihemophilic factor, recombinant) per IU
J1305	EVKEEZA (evinacumab-dgnb), 5 mg

Beta-adrenergic blocking agents (labetalol)HCPCS/CPT

J1920	Injection, labetalol hydrochloride, 5 mg — Coverage Level = Non-Specialty
J1921	Injection, labetalol hydrochloride (Hikma), not therapeutically equivalent to J1920; All NDCs inactive as of 3/18/2026

Calcium-channel blocking agentsHCPCS/CPT

J0759	Injection, clevidipine butyrate, 1 mg — Coverage Level = Not Covered
J1164	Injection, diltiazem hydrochloride in 0.72% sodium chloride, 0.5 mg — Coverage Level = Non-Specialty

Pulmonary vasodilators (treprostinil)HCPCS/CPT

J3285

Injection, treprostinil, 1 mg — Preferred Specialty; PA; Site of Service

Angptl3 inhibitor (EVKEEZA)HCPCS/CPT

J1305

Injection, evinacumab-dgnb, 5 mg — Preferred Specialty; PA; Site of Service

Loop diureticsHCPCS/CPT

J1938	Injection, furosemide, 1 mg — Coverage Level = Non-Specialty
J1941	Injection, furosemide (FUROSCIX), 20 mg — Coverage Level = Not Covered; Site of Service

Tyvaso/treprostinil inhalation and related inhaler cartridgesHCPCSCovered

J3535	Drug administered through a metered dose inhaler (refer to ADL)
J7686	Treprostinil, inhalation solution, FDA-approved final product, unit dose form, 1.74 mg

Cellular and gene therapy HCPCS/Q-codesHCPCSCovered

J3399	Injection, onasemnogene abeparvovec-xioi (Zolgensma), per treatment
J9029	Nadofaragene firadenovec-vncg, intravesical instillation
Q2041	Axicabtagene ciloleucel (YESCARTA) including leukapheresis and dose prep

Unclassified drug code usage and restrictionsHCPCSNot Covered

J3490

Unclassified drugs or biologics (example: ketamine injection listed as Not Covered)

unclassified drugs / J3490 entriesHCPCSNot Covered

J3490

Unclassified drugs (ketamine injection listed as Not Covered)

Atypical antipsychotic injectablesHCPCS

J0401	Injection, aripiprazole (ABILIFY MAINTENA), 1 mg — Non-Preferred
J0402	Injection, aripiprazole (ABILIFY ASIMTUFII), 1 mg — Preferred Specialty
J1943	Injection, aripiprazole lauroxil (ARISTADA INITIO), 1 mg — Non-Preferred
J1944	Injection, aripiprazole lauroxil (ARISTADA), 1 mg — Non-Preferred

paliperidone palmitate productsHCPCS

J2428	Injection, paliperidone palmitate extended release (ERZOFRI) — Not Covered
J2427	Injection, paliperidone palmitate extended release (INVEGA HAFYERA / TRINZA) — Preferred Specialty
J2426	Injection, paliperidone palmitate extended release (INVEGA SUSTENNA) — Preferred Specialty

risperidone injectablesHCPCSCovered

J2794	Injection, risperidone (RISPERDAL CONSTA), 0.5 mg — Preferred Specialty
J2798	Injection, risperidone (PERSERIS) — Non-Preferred
J2799	Injection, risperidone (UZEDY), 1 mg — Preferred Specialty

acetaminophen injectable codesHCPCS

J0131	Injection, acetaminophen, not otherwise specified, 10 mg — Non-Specialty
J0134	Injection, acetaminophen (Fresenius Kabi), not therapeutically equivalent to J0131 — Non-Specialty
J0136	Injection, acetaminophen (B. Braun), not therapeutically equivalent to J0131 — Non-Specialty
J0138	Injection, acetaminophen and ibuprofen (COMBOGESIC IV) — Not Covered; Site of Service

Selected injectable drug HCPCS codes in this partHCPCS | mixed

J2560	Injection, phenobarbital sodium, up to 120 mg
J2561	Injection, phenobarbital sodium (SEZABY), 1 mg — Not Covered
J2060	Injection, lorazepam, 2 mg
J0131	Injection, acetaminophen, not otherwise specified, 10 mg

Not Covered examplesHCPCSNot Covered

J0138	Injection, acetaminophen 10 mg and ibuprofen 3 mg — Not Covered; Site of Service
J0668	Instillation, bupivacaine and meloxicam, 1 mg — Not Covered
J1737	Injection, meloxicam (XIFYRM), 1 mg — Not Covered; Site of Service

inv-68: No PA required ICD-10 exceptions

ScopeSelected ICD-10 diagnosis codes exempt certain bevacizumab (J7999/J?/C9257) uses from Prior Authorization; long list includes diabetes (E08–E13 series), ocular (H21.*, H32, H34.*, H35.*), and infectious disease codes (B39.*)

Example entriesJ7999 and C9257 entries state 'No PA required' when billed with specified ICD-10 codes (see list in policy) — examples include H21.1x1-H21.1x3, H32, H34.8110-H34.8132, H35.051-H35.059, and numerous E08–E13 and B39 codes

Applicable drugsBevacizumab compound/final products (AVASTIN 100 mg/4 mL, AVASTIN 400 mg/16 mL, and compounded bevacizumab J7999 entries) are subject to these No‑PA ICD‑10 exceptions

inv-69: ICD-10 PA exceptions

ScopeCertain drugs have 'No PA required' for specified ICD‑10 codes; VELCADE (bortezomib) lists ICD‑10 ranges where PA is waived

Example — VELCADEVELCADE entry: 'No PA required for ICD‑10 codes C90.00‑C90.32, C83.10‑C83.19 and E85.81.'

How to applyWhen billing these drugs, include the specified ICD‑10 diagnosis on the claim to avoid Prior Authorization per the policy entry

inv-70: INLEXZO dose limit

Dose limitINLEXZO (J9183): 10 doses per 1 year

Maximum treatment durationMaximum 18 months treatment

Coverage levelJ9183 Coverage Level = Non‑Preferred (see J9183 Notes & Restrictions)

inv-71: ICD/CPT billing note

CPT billing noteUse CPT code 90284 for CPT billing requirements ONLY (immune globulin subcutaneous infusions)

Related J‑codesSee J1559, J1561, J1562, and J1569 for non‑CPT billing alternatives referenced in the policy

Apply to90284 entries (CU/SCIG) — Coverage Level = Preferred Specialty; Notes = PA; Site of Service

inv-72: Median Pricing Methodology effective date note

Effective dateEffective 9/1/18: code price for J7192 is based on Median Pricing Methodology

Affected codeJ7192 — Factor VIII (antihemophilic factor, recombinant) per IU

Coverage guidanceJ7192 Coverage Level = Refer to Approved Drug List (ADL); pricing note applies to stated brands and vial presentations

inv-73: authorization/administrative flags

Common administrative flagsPA — Prior Authorization; SOS — Site of Service; CC — Coverage Change; CA — Covered Alternative(s)

UsageThese flags may appear in Notes & Restrictions for individual HCPCS/CPT entries to indicate authorization, site restrictions, coverage changes, or alternatives

Policy placementPolicy repeats these abbreviations throughout drug entries (see multiple Notes & Restrictions chunks) indicating possible per‑entry application

Authorization, billing implications, and clinician responsibilities

Prior Authorization

Authorization and note codes — provider responsibilities

Prior Authorization (PA), Site‑of‑Service (SOS) restrictions, Covered Alternatives (CA), and Coverage Changes (CC) are commonly applied across many injectable and specialty drugs. Providers should request authorization when the Notes & Restrictions list PA or when an item is Not Covered with a CA that requires use of an alternative. Some drugs also require clinical documentation or adherence to the Approved Drug List (ADL) entry.

Administrative abbreviations: PA = Prior Authorization; SOS = Site of Service; CC = Coverage Change; CA = Covered Alternative(s).
Some drugs may require the provider to request authorization prior to administration; consult the Medical Drug List / ADL for clinical requirements.

Prior Authorization

Examples of PA‑required drugs / PA exceptions by diagnosis

Examples of drugs that specifically note Prior Authorization in their Notes & Restrictions or have PA waived for certain diagnoses. Providers should check code‑level notes for PA or PA exceptions tied to ICD‑10.

Examples with PA: J3490 (PREVYMIS IV) — PA noted; many oncology biologics and radiotherapeutics (A9543, A9607) list PA.
PA exceptions by diagnosis: J0614 (GRAFAPEX) — No PA required if billed with ICD-10 C92.00, C92.02, C92.A0, C92.A2, D46.Z, D46.9.
PHESGO (J9316) — PA required; No PA required if billed with ICD‑10 C50.
Bortezomib/VELCADE (J9041) — PA required; No PA required for ICD-10 codes C90.00-C90.32, C83.10-C83.19, E85.81.

Denial Risk

Not covered with covered alternatives and site‑of‑service note

Several J‑codes are listed Not Covered and direct providers to Covered Alternative(s). When CA is listed, the alternative may require prior authorization and clinical criteria per the Medical Drug List; site‑of‑service rules may also apply.

Not Covered with CA examples: J0714 (AVYCAZ) — Not Covered; CA: cefazolin, ceftriaxone, cefepime, vancomycin, imipenem‑cilastatin, meropenem, piperacillin‑tazobactam.
5th‑generation cephalosporins (J0681 ZEVTERA, J0695 ZERBAXA, J0712 TEFLARO) — Not Covered; list CAs and SOS restrictions.
Biosimilars / pegfilgrastim examples (Q5111, Q5120, Q5122, etc.) — Not Covered with CA directing to preferred pegfilgrastim products; provider may need to request authorization for the alternative.

Denial Risk

Carbapenem not covered flags — check CAs and SOS

Carbapenem products include explicit Not Covered flags and site‑of‑service or CA restrictions. Verify coverage status and allowable alternatives before administration.

J0742 (RECARBRIO) — Not Covered; Site of Service.
J2186 (VABOMERE) — Not Covered; CA includes cefazolin, ceftriaxone, cefepime, vancomycin, imipenem‑cilastatin, meropenem, piperacillin‑tazobactam; Site of Service.

Prior Authorization

Prior Authorization / Site of Service notes — specialty & cellular therapies

Site‑of‑Service restrictions and PA are applied to many specialty, oncology, cellular and gene therapies. Billing with the appropriate HCPCS/CPT and following OPPS rules is required; unclassified codes (C9399, J3490, J3590) may have hospital‑only or ADL guidance.

Cellular/Gene Therapy: C9399, J3590 entries — PA; Cellular/Gene Therapy designation; Site of Service.
Unclassified codes: C9399 or J3590 — Hospital Outpatient Use ONLY in some entries; refer to ADL for coding/coverage.
Common PA + SOS examples: many oncology biologics (e.g., J9022 TECENTRIQ, J9023 BAVENCIO) list PA; Site of Service.

Note

PA exceptions and preventive billing

Preventive and HIV pre‑exposure prophylaxis (PrEP) items can have special billing rules where PA is waived if billed with preventive ICD‑10 codes. Confirm preventive coverage and quantity limits when applicable.

HIV prevention: J0738 (lenacapavir SC) and J0752 (lenacapavir oral) — No PA required if billed with ICD‑10 Z29.81; may be covered as preventive at 100% per plan documents; quantity limits apply (example: lenacapavir SC: 2 injections/yr).
RSV monoclonal antibodies: BEYFORTUS (90380/90381) — Marked Preventive and PA required; SYNAGIS (90378) Not Covered; SOS noted.

Denial Risk

Denial risk / site‑of‑service limitations

Some drugs are Not Covered as stand‑alone injections or carry denial risk if billed incorrectly. Ketamine injections, for example, are only covered when billed with an anesthesia service for a covered procedure.

Ketamine (J3490) — Not Covered as standalone; Site of Service; CC note: covered only when billed in conjunction with an anesthesia service for a covered procedure.
Clevidipine (J0759) — Not Covered; Site of Service limits.
Many Not Covered entries include a Site of Service restriction — check plan rules to avoid denials.

Billing Rule

Specialty drug coding references and restrictions

Certain codes require referral to the Approved Drug List (ADL) or have specific billing coding guidance. Use ADL references and the specified HCPCS/CPT code (not generic J3490/J9999) where indicated to ensure correct reimbursement.

J3535 and J7340 entries: refer to Approved Drug List (ADL) for coding/coverage guidance.
Unclassified codes (C9399, J3490, J3590) — use only per guidance; some entries restrict to hospital outpatient or ADL.
Examples: J3032 VYEPTI, J7340 DUOPA, and C9399 ONAPGO reference ADL or PA requirements.

Documentation Required

Prior authorization and billing notes — provider checklist

Prior authorization and billing reminders for providers: confirm PA requirements, verify whether No PA applies for specific ICD‑10 diagnoses, follow Site‑of‑Service rules, and consult the Medical Drug List/ADL when Covered Alternatives are listed.

Check code‑level Notes & Restrictions for PA, SOS, CC, and CA before drug administration.
When CA is listed, review the ADL and be prepared to request authorization for the covered alternative.
Some items waive PA if billed with specific ICD‑10 codes — document appropriate diagnosis codes on the claim.

Note

Administrative abbreviations and actions

Additional administrative reminders and common restriction flags used throughout the drug list. Learn these abbreviations to interpret drug entries quickly and act accordingly.

PA = Prior Authorization
SOS = Site of Service
CC = Coverage Change
CA = Covered Alternative(s)

Denial Risk

SEZABY & ERZOFRI coverage alternative and authorization note

Other specific Not Covered with Covered Alternative examples to check before administering or billing: ERZOFRI (J2428) and SEZABY (J2561) are Not Covered and direct providers to listed covered alternatives; providers may need to request authorization for the alternative.

J2428 (ERZOFRI) — Not Covered; CA: J2427 and J2426 (Invega Hafyera/Trinza and Invega Sustenna); Site of Service.
J2561 (SEZABY) — Not Covered; CA: J2560 (phenobarbital sodium); Site of Service.

Billing Rule

Prior Authorization and ADL references

References to the Approved Drug List (ADL) and PA for certain specialty or unclassified drugs are frequent. When an entry says 'Refer to ADL' or lists C9399/J3490, consult the ADL for clinical criteria and billing instructions.

Examples: J3535, J3031/J3032 entries reference ADL.
C9399 and J3490 are used for unclassified drugs — check ADL and site‑of‑service notes; some C9399 entries are Not Covered or Hospital Outpatient only.
C9399 ONAPGO and other ADL‑referenced items may still require PA and SOS constraints.

Terms, abbreviations, and billing guidance

inv-109: format and notation

Generic vs Brand notationlowercase italics = Generic drugs; UPPERCASE = Brand name drugs

Line detailEach HCPCS/CPT line includes a Coverage Level and Notes & Restrictions field accompanying the code entry

PurposeFormat clarifies naming conventions and where coverage stance and restrictions are presented on each HCPCS/CPT line

inv-110: administrative flags

PAPrior Authorization

SOSSite of Service

CCCoverage Change

inv-111: PA = Prior Authorization; SOS = Site of Service; CC = Coverage Change; CA = Covered Alternative(s)

PAPrior Authorization

SOSSite of Service

CACovered Alternative(s)

inv-112: Coverage Level

DefinitionCoverage Level indicates plan stance: e.g., Non‑Specialty, Preferred Specialty, Non‑Preferred, Not Covered, or referral to Approved Drug List (ADL)

PlacementDisplayed on each HCPCS/CPT line alongside Notes & Restrictions

ImplicationCoverage Level directs billing and authorization expectations per code entry

inv-113: Prior Authorization

PAPrior Authorization (abbreviation used in Notes & Restrictions)

ContextMany specialty and selected drug entries include 'PA' in their Notes & Restrictions indicating authorization needed prior to administration

ReferenceSee specific HCPCS/CPT lines for per‑drug PA instructions

inv-114: Unclassified drugs or biologicals (hospital outpatient use only; for drugs/biologics approved on or after 1/1/2004) — C9399

Unclassified codeC9399 — Unclassified drugs or biologicals (hospital outpatient use only; for drugs/biologics approved on or after 1/1/2004)

Use caseUsed for newly approved products or when no specific J‑code exists; often linked to ADL and PA/SOS flags

Coverage noteCoverage Level for C9399 entries varies (e.g., Cellular/Gene Therapy, Non‑Preferred, Refer to ADL) — check specific entry

inv-115: Item is not separately reimbursable (e.g., J0911 Defencath)

Not separately reimbursableExamples: J0911 (Defencath) is Not Separately Payable

ImplicationSome items appear on the drug list but are not separately reimbursable — billing guidance should be followed

ReferenceSee individual line 'Coverage Level = Not Separately Payable' for details

inv-116: Prior Authorization — PA

PAPrior Authorization (abbrev. 'PA' used in Notes & Restrictions)

Common usePA flags appear across oncology and specialty drug entries to indicate authorization requirement

ActionProviders should check Notes & Restrictions for PA requirement per HCPCS/CPT line

inv-117: Site of Service — SOS

SOSSite of Service (abbrev. 'SOS')

MeaningIndicates site‑of‑service restrictions on coverage for the HCPCS/CPT code (e.g., outpatient vs inpatient)

ActionFollow Notes & Restrictions to determine allowable site for administration

inv-118: Covered Alternative(s) — CA

CACovered Alternative(s) — lists alternative HCPCS/J codes that are covered when the primary code is Not Covered

ExampleAVASTIN entries reference CA alternatives such as biosimilars Q5107/Q5118 for non‑ophthalmic coverage

ImplicationIf a code is Not Covered with CA, provider may substitute the covered alternative per clinical appropriateness and payer rules

inv-119: Prior Authorization — PA

PAPrior Authorization is indicated where 'PA' appears in Notes & Restrictions

ActionVerify PA requirements before administration to avoid claim denials

Where foundPA appears in many specialty, oncology, gene/cellular therapy, and select infusion products' Notes & Restrictions

inv-120: Site of Service — SOS

9028490284 — Immune globulin (SCIg) for subcutaneous infusion; 'Use 90284 for CPT billing requirements ONLY'

Notes90284 Coverage Level = Preferred Specialty; Notes = PA; Site of Service

AlternativesSee J‑codes (J1559, J1561, J1562, J1569) for non‑CPT billing options

inv-121: Covered Alternative(s) — CA

CCCoverage Change (abbrev. 'CC')

UsageDenotes entries where coverage level has changed or special coverage policy applies

ActionReview Notes & Restrictions for details when CC appears

inv-122: CA — Covered Alternative(s)

CACovered Alternative(s)

PAPrior Authorization

SOSSite of Service

inv-123: PA — Prior Authorization

PAPrior Authorization

NoteThe policy uses 'PA' consistently to flag drugs requiring prior authorization in Notes & Restrictions

Provider actionSubmit PA per payer instructions for PA‑flagged drugs

inv-124: SOS — Site of Service

SOSSite of Service — indicates where administration is allowed/required

ExamplesMany oncology and specialty agents show 'SOS' in Notes & Restrictions to indicate site constraints

ActionConfirm allowed site before scheduling administration to ensure coverage

inv-125: CC — Coverage Change

CCCoverage Change

ContextUsed with other flags (PA, SOS, CA) to denote modifications to coverage status

Provider implicationCheck claim and ADL guidance when CC appears to determine current coverage stance

inv-126: Prior Authorization — PA

PAPrior Authorization — authorization requirement noted in entries' Notes & Restrictions

FrequencyCommon across specialty, oncology, and high‑cost injectable drug entries

ActionProviders should obtain authorization where PA is listed to avoid denials

inv-127: Site of Service — SOS

SOSSite of Service — used to indicate site constraints in Notes & Restrictions

ReferenceAppears repeatedly across the drug list indicating site‑specific coverage rules

ActionConfirm allowed service location prior to administration

inv-128: Covered Alternative(s) — CA

CACovered Alternative(s) — alternative codes listed when primary code is Not Covered

ExampleJ9312 lists CA alternatives Q5123/Q5119/Q5115 for rituximab biosimilars

ActionConsider covered alternatives per clinical appropriateness when primary code is Not Covered

inv-129: Notes & Restrictions abbreviations

Notes abbreviationsPA = Prior Authorization; SOS = Site of Service; CC = Coverage Change; CA = Covered Alternative(s)

Where usedAppears in Notes & Restrictions across many HCPCS/CPT entries

Provider implicationInterpret these flags per line item when determining authorization and billing actions

inv-130: J7677 status

J7677 statusJ7677 listed as Not Covered with Coverage Level = Site of Service for an FDA‑approved final product administered through DME

ImplicationSpecific product billing and site‑of‑service rules apply — see entry for details

ActionDo not bill J7677 for covered DME‑administered final products unless site and coverage conditions are met

inv-131: Prior Authorization — PA

PAPrior Authorization

NoteUsed throughout as shorthand in Notes & Restrictions

ActionFollow per‑line PA instructions

inv-132: Site of Service — SOS

SOSSite of Service

NoteIndicates site constraints for coverage

ActionConfirm site eligibility before service

inv-133: Covered Alternative(s) — CA

CACovered Alternative(s)

UseLists acceptable alternative HCPCS/J codes when primary is Not Covered

Provider actionRefer to listed alternatives when primary code is disallowed

inv-134: Approved Drug List (ADL); many entries instruct to refer to ADL for coverage level

Common flagsPA = Prior Authorization; SOS = Site of Service; CC = Coverage Change; CA = Covered Alternative(s)

FrequencyRepeated throughout the document to annotate Notes & Restrictions

InterpretationTreat these flags as actionable indicators for billing and authorization workflows

inv-135: Common flags meaning Prior Authorization (PA), Site of Service (SOS), Coverage Change (CC), Covered Alternative(s) (CA)

PAPrior Authorization (PAP) shorthand appears in chunk notes

ContextUsed alongside other abbreviations to signal administrative requirements

ActionCheck per‑code Notes & Restrictions for PA specifics

inv-136: PA — Prior Authorization (as used in notes & restrictions)

PAPrior Authorization — used in Notes & Restrictions

MeaningIndicates prior authorization required before administration for coverage

ActionObtain PA when indicated to avoid claim denial

inv-137: SOS — Site of Service (site-of-service restrictions noted in several entries)

SOSSite of Service — indicates site restrictions in Notes & Restrictions

ImplicationNoncompliance with SOS can result in denial or different reimbursement

ActionVerify allowed service location prior to treatment

inv-138: Coverage Level — Plan-designated classification

Coverage Level - definitionPlan‑designated classification values such as Non‑Specialty, Preferred Specialty, Non‑Preferred, Not Covered, or referral to Approved Drug List (ADL)

UseDisplayed on each HCPCS/CPT line to indicate payer stance

ActionFollow coverage level when determining billing and authorization steps

inv-139: Plan abbreviations

AbbreviationsPA = Prior Authorization; SOS = Site of Service; CC = Coverage Change; CA = Covered Alternative(s)

RepetitionThese plan abbreviations are repeated across entries to signal administrative actions

Provider implicationInterpret per‑line when present to determine next steps

inv-140: ADL reference

ADL referenceRefer to Approved Drug List (ADL) — indicates coverage level or coding details are determined by the payer's ADL

Where usedMany factor products, inhalation cartridges, and unclassified biologics reference ADL in their entries

ActionConsult the payer's ADL for definitive coverage and coding guidance when ADL is referenced

inv-141: Prior Authorization — PAP

PAPPrior Authorization (PAP) abbreviation appears in Notes & Restrictions

ContextUsed as shorthand across chunked Notes & Restrictions

ActionWhere PAP appears, follow PA process as required by payer

inv-142: Site of Service — SOS

SOSSite of Service (SOS) abbreviation repeated in Notes & Restrictions

MeaningIndicates site constraints for coverage per code entry

ActionConfirm site eligibility before billing

inv-143: Covered Alternative(s) — CA

CACovered Alternative(s) abbreviation repeated in Notes & Restrictions

MeaningLists covered alternative codes when primary is Not Covered

ActionUse alternatives where clinically appropriate and per payer guidance

inv-144: Coverage Change — CC

CCCoverage Change (abbrev.)

UseSignals coverage updates or specific coverage modifiers for entries

ActionReview Notes & Restrictions for CC entries before billing

inv-145: policy abbreviations

AbbreviationsPA = Prior Authorization; SOS = Site of Service; CC = Coverage Change; CA = Covered Alternative(s)

Document usePolicy uses these standard abbreviations throughout to annotate Notes & Restrictions

Provider instructionInterpret these per code entry when planning billing/authorization actions

Policy Summary

Payerpriority health

PolicyPriority Health medical drug coverage list (partial)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line indicates PA before administering or billing the drug.

SourceLink

On This Page