Type of Care

Code(s)​

Commercial

Medicare
Advantage

Precertification Performed by

Inpatient Services

Acute rehabilitation admissions

NA

Y

Y

IBX

Elective surgical and nonsurgical inpatient admissions

NA

Y

Y

IBX

Inpatient hospice admissions

NA

Y

Y

IBX

Long term acute care (LATC) facility admissions

NA

Y

Y

IBX

Skilled nursing facility admissions

NA

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Home Services

Home-care services

NA

Y

Y

Commercial - IBX
Medicare Advantage - Tango

Home infusion services

NA

Y

Y

Commercial - IBX
Medicare Advantage - Tango

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Cardiology

Arterial Ultrasound

93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93978, 93979

Y

Y

Carelon

Diagnostic Coronary Angiography

93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7552, C7553, C7557, C7562, C7568, C7569, C7570

Y

Y

Carelon

Percutaneous Coronary Intervention

92920, 92924, 92928, 92930, 92933, 92937, 92943, 92945, C9600, C9602, C9604, C9607

Y

Y

Carelon

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Otolaryngology

Cochlear Implant Surgery and Associated Supplies/Bone-Anchored (Osseointegrated) Hearing Aids, Implantable Bone Conduction Hearing Aids

69714, 69715, 69717, 69718, 69930, L8614, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Bariatric Services

Obesity Surgery

43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Musculoskeletal Services

Bone Grafts

20930, 20931, 20932, 20933, 20934, 20936, 20937, 20938

Y

Y

Carelon

Bone Growth Stimulator

E0748

Y

Y

Carelon

Cervical Spine Surgery - Anterior Decompression with Fusion

22551, 22552, 22554, 22585, 22830, 63081, 63082

Y

Y

Carelon

Cervical Spine Surgery - Anterior Decompression without Fusion

63075, 63076

Y

Y

Carelon

Cervical Spine Surgery - Posterior Decompression with Fusion

22600, 22614, 22632, 22634, 22830, 22864

Y

Y

Carelon

Cervical Spine Surgery - Posterior Decompression without Fusion

63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051, 63052, 63053

Y

Y

Carelon

Cervical Total Disc Replacement (Arthroplasty)

22856, 22858, 22861, 22864, 0095T, 0098T

Y

Y

Carelon

Hip Arthroscopy

27120, 27122, 29860, 29861, 29862, 29863, 29914, 29915, 29916

Y

Y

Carelon

Hip Replacement

27125, 27130, 27132, 27134, 27137, 27138, S2118

Y

Y

Carelon

Knee Arthroscopy

29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Y

Y

Carelon

Knee Open

27331, 27332, 27333, 27334, 27335, 27345, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429

Y

Y

Carelon

Knee Replacement

27437, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27486, 27487, 27488, J7330, S2112

Y

Y

Carelon

Lumbar Decompression
(Laminotomy/ 
Laminectomy/

Discectomy/ Foraminotomy)

63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, S2350, S2351

Y

Y

Carelon

Lumbar Disc Replacement (Arthroplasty)

22857, 22860, 22862, 22865, 0164T, 0165T

Y

Y

Carelon

Lumbar Fusion

22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22830

Y

Y

Carelon

Sacroiliac Joint Fusion

27279, 27280, C1737

Y

Y

Carelon

Shoulder - Arthroscopic and Open Procedures

23105, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828

Y

Y

Carelon

Shoulder Replacement

23470, 23472, 23473, 23474

Y

Y

Carelon

Spinal Deformity (Scoliosis/Kyphosis)

22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22610, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308

Y

Y

Carelon

Spinal Instrumentation

22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859

Y

Y

Carelon

Vertebroplasty, Kyphoplasty

22510, 22511, 22512, 22513, 22514, 22515, C7504, C7505, C7507, C7508

Y

Y

Carelon

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Interventional Pain Management

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks - Cervical or Thoracic Epidural Steroid Injection

62320, 62321, 64479, 64480

Y

Y

Carelon

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks - Lumbar or Sacral Epidural Steroid Injection

62323, 64483, 64484

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Cervical or Thoracic Facet Injection

64490, 64491, 64492

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Cervical Radiofrequency Ablation

64633, 64634

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Lumbar or Sacral Facet Injection

64493, 64494, 64495

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Lumbar Radiofrequency Ablation

64635, 64636

Y

Y

Carelon

Regional Sympathetic Nerve Blocks

64510, 64520

Y

Y

Carelon

Sacroiliac Joint injections

27096, G0260

Y

Y

Carelon

Spinal Cord and Nerve Root Stimulators - Implantation of Spinal Cord Stimulators

63650, 63655, 63663, 63664, 63685, 63688

Y

Y

Carelon

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Reconstructive Procedures and Potentially Cosmetic Procedures

Blepharoplasty/Ptosis Repair

15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909

Y

Y

IBX

Bone Graft, Genioplasty and Mentoplasty

21120, 21121, 21122, 21123

Y

Y

IBX

Breast Augmentation/
Mammoplasty

19325

Y

Y

IBX

Breast Mastopexy

19316

Y

Y

IBX

Breast Reconstruction

11920, 11921, 11922, 11970, 11971, 15271, 15272, 15769, 15771, 15772, 15773, 15774, 15777, 19300, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4107, Q4116, Q4130, Q4142, Q4143, S2066, S2067, S2068

Y

Y

IBX

Breast Reduction

15877, 19318

Y

Y

IBX

Canthopexy/
Canthoplasty

21280, 21282, 67950

Y

Y

IBX

Cervicoplasty

17999

Y

Y

IBX

Chemical Peels

15788, 15789, 15792, 15793

Y

Y

IBX

Dermabrasion

15780, 15781, 15782, 15783

Y

Y

IBX

Excision of Excessive Skin and/or Subcutaneous Tissue

15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839

Y

Y

IBX

Gender Affirming Interventions

11920, 11921, 11922, 11960, 15877, 17380, 19303, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720

Y

Y

IBX

Genetically and Bio-Engineered Skin Substitutes for Wound Care

A2001, A2002, A2004, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021, A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039, A4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4183, Q4184, Q4185, Q4186, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4227, Q4229, Q4230, Q4232, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4314, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4344, Q4345, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4368, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397, Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433

Y

Y

IBX

Hair Transplant

15775, 15776

Y

Y

IBX

Insertion of Breast Implants

19340, 19342, 19396

Y

Y

IBX

Keloid Removal

13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830

Y

Y

IBX

Lipectomy, Liposuction, or Any Other Excess Fat-Removal Procedure

15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879

Y

Y

IBX

Otoplasty

13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399

Y

Y

IBX

Removal of Breast Implants

19328, 19330, 19370, 19371

Y

Y

IBX

Rhinoplasty

30400, 30410, 30420, 30430, 30435, 30450

Y

Y

IBX

Rhytidectomy

15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876

Y

Y

IBX

Scar Revision

13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830

Y

Y

IBX

Skin Closures

13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770

Y

Y

IBX

Surgery for Varicose Veins, Including Perforators and Sclerotherapy

36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, S2202

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Day Rehabilitation

Day Rehabilitation Programs

0931, 0932

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Elective (Nonemergency) Ground, Air, and Sea Ambulance Transportation

Elective (Nonemergency) Ground, Air, and Sea Ambulance Transportation

A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Outpatient Private-Duty Nursing

Outpatient Private-Duty Nursing

S9123, S9124

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Outpatient Radiation Therapy

Brachytherapy

77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, 0395T, C2616, G0458

Y

Y

eviCore

Cardiac Focal Ablation

0747T

Y

Y

eviCore

Hyperthermia Treatment

77600, 77605, 77610, 77615, 77620

Y

Y

eviCore

Image-Guided Radiation (IGRT)

77387

Y

Y

eviCore

Intraoperative Radiation Therapy (IORT)

77424, 77425

Y

Y

eviCore

Neuro SRS

61796, 61797, 61798, 61799, 61800

N

Y

eviCore

Neutron Beam Radiation Therapy

77423

Y

Y

eviCore

Proton Beam Radiation Therapy

77520, 77522, 77523, 77525

Y

Y

eviCore

Radiation Treatment Delivery

77402, 77407, 77412, 77437, 77438, 77439, A9609

Y

Y

eviCore

Radiation Treatment Planning

G0562

N

Y

eviCore

Radiation Treatment Planning

G0563

Y

Y

eviCore

Stereotactic Radiation Therapy

77371, 77372, 77373, G0339, G0340

Y

Y

eviCore

Therapeutic Radiopharmaceuticals

79005, 79101, A9513, A9606, A9607, A9699, S2095

Y

Y

eviCore

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Radiology

3-D Rendering - Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Grouping

76376, 76377

Y

Y

Carelon

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET) / Computed Tomography (CT) - Computed Tomography (CT) Heart for Calcium Scoring

75571

Y

Y

Carelon

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET) / Computed Tomography (CT) - Coronary Computed Tomography (CT) and Computed Tomography Angiography (CTA) Scoring

75572, 75573, 75574, 75580

Y

Y

Carelon

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET) / Computed Tomography (CT) - Tumor Imaging

78811, 78812, 78813, 78814, 78815, 78816

Y

Y

Carelon

Computed Tomography (CT) - Abdomen

74150, 74160, 74170

Y

Y

Carelon

Computed Tomography (CT) - Abdomen and Pelvis

74176, 74177, 74178

Y

Y

Carelon

Computed Tomography (CT) - Cervical Spine

72125, 72126, 72127

Y

Y

Carelon

Computed Tomography (CT) - Chest

71250, 71260, 71270

Y

Y

Carelon

Computed Tomography (CT) - Head

70450, 70460, 70470, 70471, 70473

Y

Y

Carelon

Computed Tomography (CT) - Lower Extremity

73700, 73701, 73702

Y

Y

Carelon

Computed Tomography (CT) - Lumbar Spine

72131, 72132, 72133

Y

Y

Carelon

Computed Tomography (CT) - Lung

71271

Y

Y

Carelon

Computed Tomography (CT) - Neck

70490, 70491, 70492

Y

Y

Carelon

Computed Tomography (CT) - Orbit

70480, 70481, 70482

Y

Y

Carelon

Computed Tomography (CT) - Pelvis

72192, 72193, 72194

Y

Y

Carelon

Computed Tomography (CT) - Sinus

70486, 70487, 70488

Y

Y

Carelon

Computed Tomography (CT) - Thoracic Spine

72128, 72129, 72130

Y

Y

Carelon

Computed Tomography (CT) - Upper Extremity

73700, 73701, 73702

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Abdomen

74175

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Abdomen and Pelvis

74174

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Abdominal Arteries

75635

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Chest

71275

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Head

70496

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Lower Extremity

73706

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Lung

71271

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Neck

70498

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Pelvis

72191

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Upper Extremity

73206

Y

Y

Carelon

Diagnostic Computed Tomography (CT) Colonoscopy

74261, 74262

Y

Y

Carelon

Fluorine-18 fluorodeoxyglucose (f-18 FDG)

S8085

Y

Y

Carelon

Follow Up Study Computed Tomography (CT)

76380

Y

Y

Carelon

Functional Magnetic Resonance Imaging (MRI) Brain

70554, 70555

Y

Y

Carelon

Low-Field MRI

S8042

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Abdomen

74185, C8900, C8901, C8902

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Chest

71555, C8909, C8910, C8911

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Head

70547, 70548, 70549, 0615

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Pelvis

72198, C8918, C8920

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Spinal Canal

72159, C8931, C8932, C8933

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Upper Extremity

73225, C8934, C8935, C8936

Y

Y

Carelon

Magnetic Resonance Elastography

76391

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Abdomen

74181, 74182, 74183, S8037

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Bone Marrow

77084

Y

N

Carelon

Magnetic Resonance Imaging (MRI) - Brain

70551, 70552, 70553

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Breast

77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Cardiac

75557, 75559, 75561, 75563, 75565, C9762, C9763

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Cervical Spine

72141, 72142, 72156

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Chest

71550, 71551, 71552

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Fetal

74712, 74713

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Lower Extremity

73718, 73719, 73720, 73721, 73722, 73723

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Lumbar Spine

72148, 72149, 72158

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Orbit

70540, 70542, 70543

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Pelvis

72195, 72196, 72197

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Temporomandibular Joint (TMJ)

70336

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Thoracic Spine

72146, 72147, 72157

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Upper Extremity (Any Joint)

73221, 73222, 73223

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Upper Extremity (Non-Joint)

73218, 73219, 73220

Y

Y

Carelon

Magnetic Resonance Technology (MRT)

0616

Y

Y

Carelon

Magnetoencephalography (MEG) - Head

95965, 95966

Y

Y

Carelon

Nuclear Cardiology - Cardiac Blood Pool Imaging

78472, 78473, 78481, 78483, 78494, 78496

Y

Y

Carelon

Nuclear Cardiology - Infarct Imaging

78451, 78452, 78453, 78454, 78466, 78468, 78469, 0742T

Y

Y

Carelon

Positron Emission Tomography (PET) - Brain Imaging

78608, 78609

Y

Y

Carelon

Positron Emission Tomography (PET) - Myocardial Imaging

78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492

Y

Y

Carelon

Positron Emission Tomography (PET) - Other Imaging Services

0404

Y

Y

Carelon

Quantitative Computed Tomography (QCT) Bone Densitometry

77078

Y

Y

Carelon

Resting Transthoracic Echocardiography (TTE)

93303, 93304, 93306, 93307, 93308

Y

Y

Carelon

Resting Transthoracic Echocardiography (TTE) - Echocardiography Add-On Codes

93320, 93321, 93325

Y

Y

Carelon

Screening Computed Tomography (CT) Colonoscopy

74263

Y

Y

Carelon

Stress Echocardiography

93350, 93351

Y

Y

Carelon

Stress Echocardiography - Echocardiography Add-On Codes

93320, 93321, 93325, 93352

Y

Y

Carelon

Transesophageal Echocardiography (TEE)

93312, 93313, 93314, 93315, 93316, 93317

Y

Y

Carelon

Transesophageal Echocardiography (TEE) - Echocardiography Add-On Codes

93319, 93320, 93321, 93325

Y

Y

Carelon

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Prosthetics/Orthoses

Custom Ankle-Foot Orthoses

L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4361

Y

Y

IBX

Custom Knee Braces

L1834, L1840, L1844, L1846, L1860

Y

Y

IBX

Custom Knee-Ankle-Foot Orthoses

L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128

Y

Y

IBX

Custom Limb Prosthetics Including Accessories/
​Components

L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5657, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6028, L6029, L6030, L6031, L6032, L6033, L6034, L6035, L6036, L6037, L6038, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6700, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7400, L7401, L7402, L7403, L7404, L7405, L7406, L7499

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Selected Durable Medical Equipment (DME)

For repair or replacement of all DME items, as well as orthoses and prosthetics that require precertification, see the specific DME, orthoses, and prosthetics categories, for repair or replacement codes that require precertification.

Bone Growth Stimulators - Low-Intensity Ultrasound Noninvasive Bone Growth Stimulation

E0760

Y

Y

IBX

Bone Growth Stimulators - Other Than Spinal Noninvasive Electrical Bone Growth Stimulation

E0747

Y

Y

IBX

Bone Growth Stimulators - Spinal Noninvasive Electrical Bone Growth Stimulation

E0748

Y

Y

IBX

Bone-Anchored (Osseointegrated) Hearing Aids

69716, 69719, 69726, 69727, 69728, 69729, 69730, L8690, L8691, L8692, L8693, L8694

Y

Y

IBX

Continuous Positive Airway Pressure (CPAP) Devices, Bi-Level (Bi-PAP) Devices, and All Supplies

A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0470, E0471, E0561, E0562, E0601

Y

Y

Carelon

Dynamic Adjustable and Static Progressive Stretching Devices (excludes CPMs)

E1800, E1802, E1805, E1810, E1812, E1825, E1830

Y

Y

IBX

Electric, Power, and Motorized Wheelchairs Including Custom Accessories

E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294, E2298, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, K0010, K0011, K0012, K0013, K0014, K0056, K0108, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0890, K0891, K0898

Y

Y

IBX

Electric, Power, and Motorized Wheelchairs Including Custom Accessories

K0830, K0831

N

Y

IBX

Insulin Pumps

E0784, E0787, S1034

Y

Y

IBX

Manual Wheelchairs with the Exception of those that are Rented

E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108

Y

Y

IBX

Negative Pressure Wound Therapy

A6550, A9272, E2402, K0743, K0744, K0745, K0746

Y

Y

IBX

Neuromuscular Stimulators

E0744, E0745, E0764, E0770

Y

Y

IBX

Power Operated Vehicles (POV)

E1230, K0800, K0801, K0802, K0812

Y

Y

IBX

Pressure Reducing Support Surfaces - Air Fluidized Bed

E0194

Y

Y

IBX

Pressure Reducing Support Surfaces - Non-Powered Advanced Pressure Reducing Mattress

E0371, E0373

Y

Y

IBX

Pressure Reducing Support Surfaces - Powered Air Flotation Bed (Low Air Loss Therapy)

E0193, E0372

Y

Y

IBX

Pressure Reducing Support Surfaces - Powered Pressure Reducing Mattress

E0277

Y

Y

IBX

Push Rim Activated Power Assist Devices

E0986

Y

Y

IBX

Speech Generating Devices

E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Medical Foods

Medical Foods

B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Hyperbaric Oxygen Therapy

Hyperbaric Oxygen Therapy

G0277, 0413

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

In-Lab / Facility Sleep Studies

In-Lab / Facility Sleep Studies

95782, 95783, 95805, 95807, 95808, 95810, 95811

Y

Y

Carelon

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

All Transplant Procedures, with the Exception of Corneal Transplants

All Transplant Procedures, with the Exception of Corneal Transplants

32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, 0584T, 0585T, 0586T, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Mental Health/Serious Mental Illness/Substance Abuse

Repetitive transcranial magnetic stimulation (rTMS)

90867, 90868, 90869, 0889T, 0890T, 0891T, 0892T

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Applied Behavioral Analysis

Applied Behavioral Analysis

97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T

Y

Y

IBX

Type of Care

Code(s)

Commercial

Medicare
Advantage

Precertification Performed by

Genetic and Genomic Tests

Any genetic test that is billed with a non-specific procedure code that requires precertification. This includes genetic tests billed with CPT® codes 81400 through 81408 as well as unlisted CPT® codes 81479, 81599, and 84999.

Genetic and Genomic Tests

81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81195, 81200, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81221, 81222, 81223, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81238, 81248, 81249, 81252, 81253, 81257, 81258, 81259, 81269, 81277, 81283, 81286, 81289, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81308, 81313, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 81326, 81327, 81328, 81335, 81336, 81337, 81346, 81349, 81350, 81351, 81353, 81354, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81479, 81493, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81524, 81525, 81529, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 81558, 81595, 81599, 84999, 87183, 87494, 87627, 0001U, 0004M, 0005U, 0006M, 0007M, 0011M, 0012M, 0013M, 0016M, 0016U, 0017M, 0017U, 0018U, 0019U, 0020M, 0022U, 0026U, 0029U, 0030U, 0031U, 0032U, 0034U, 0036U, 0037U, 0045U, 0047U, 0048U, 0050U, 0055U, 0060U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0133U, 0134U, 0136U, 0137U, 0138U, 0153U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0179U, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0329U, 0331U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0355U, 0356U, 0362U, 0363U, 0363U, 0364U, 0368U, 0379U, 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0418U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0444U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0488U, 0489U, 0493U, 0494U, 0495U, 0496U, 0497U, 0498U, 0499U, 0501U, 0506U, 0507U, 0510U, 0516U, 0523U, 0529U, 0530U, 0532U, 0533U, 0534U, 0536U, 0537U, 0538U, 0539U, 0540U, 0543U, 0549U, 0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U, 0572U, 0600U, 0602U, 0605U, 0607U, 0608U, 0611U, 0612U, 0613U, G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3850, S3852, S3854, S3861, S3865, S3866, S3870

Y

Y

eviCore

Drug Name

Code

Commercial

Medicare
Advantage

Precertification Performed by

Specialty Drugs

For specialty drugs, all listed brands and their generic equivalents or biosimilars require precertification.

Alzheimer’s Disease Agents

Leqembi®

J0174

N

Y

IBX

Kisunla™

J0175

N

Y

IBX

Amyotrophic Lateral Sclerosis Agents

Qalsody®

J1304

Y

Y

IBX

NurOwn®

J3490, J3590, C9399

Y

Y

IBX

Antineoplastic Agents

Azedra®

A9590

Y

Y

eviCore

Pluvicto™

A9607

Y

Y

eviCore

Avastin®

C9257

Y

Y

IBX

Rytelo™

J0870

Y

Y

IBX

Elrexfio™

J1323

Y

Y

IBX

Vyloy®

J1326

Y

Y

IBX

Talvey™

J3055

Y

Y

IBX

Taclantis

J3490, J3590

Y

Y

IBX

Avzivi®

J3490, J3590, C9399

Y

Y

IBX

Patritumab deruxtecan

J3490, J3590, C9399

Y

Y

IBX

Blenrep

J3590, C9399

Y

Y

IBX

Datroway®

J9011

Y

Y

IBX

Rylaze™

J9021

Y

Y

IBX

Anktiva®

J9028

Y

Y

IBX

Adstiladrin®

J9029

Y

Y

IBX

Avastin®

J9035

Y

Y

IBX

Blincyto™

J9039

Y

Y

IBX

Adcetris®

J9042

Y

Y

IBX

Kyprolis®

J9047

Y

Y

IBX

Erbitux®

J9055

Y

Y

IBX

Rybrevant™

J9061

Y

Y

IBX

Elahere™

J9063

Y

Y

IBX

Darzalex Faspro™

J9144

Y

Y

IBX

Darzalex™

J9145

Y

Y

IBX

Padcev™

J9177

Y

Y

IBX

Poteligeo®

J9204

Y

Y

IBX

Zepzelca™

J9223

Y

Y

IBX

Sarclisa®

J9227

Y

Y

IBX

Yervoy™

J9228

Y

Y

IBX

Abraxane®

J9264

Y

Y

IBX

Tivdak™

J9273

Y

Y

IBX

Kimmtrak®

J9274

Y

Y

IBX

Ziihera®

J9276

Y

Y

IBX

Columvi™

J9286

Y

Y

IBX

Opdualag™

J9298

Y

Y

IBX

Pemfexy™

J9304

Y

Y

IBX

Perjeta®

J9306

Y

Y

IBX

Cyramza®

J9308

Y

Y

IBX

Polivy™

J9309

Y

Y

IBX

Rituxan Hycela™

J9311

Y

Y

IBX

Rituxan®

J9312

Y

Y

IBX

Phesgo™

J9316

Y

Y

IBX

Trodelvy®

J9317

Y

Y

IBX

Epkinly™

J9321

Y

Y

IBX

Emrelis™

J9326

Y

Y

IBX

Imjudo®

J9347

Y

Y

IBX

Monjuvi®

J9349

Y

Y

IBX

Lunsumio™

J9350

Y

Y

IBX

Margenza™

J9353

Y

Y

IBX

Kadcyla®

J9354

Y

Y

IBX

Herceptin®

J9355

Y

Y

IBX

Herceptin® Hylecta

J9356

Y

Y

IBX

Enhertu®

J9358

Y

Y

IBX

Zynlonta™

J9359

Y

Y

IBX

Tecvayli™

J9380

Y

Y

IBX

Bizengri®

J9382

Y

Y

IBX

Provenge®

Q2043

Y

Y

IBX

Herzuma®

Q5113

Y

Y

IBX

Trazimera®

Q5116

Y

Y

IBX

Alymsys®

Q5126

Y

Y

IBX

Hercessi™

Q5146

Y

Y

IBX

Jobevne

Q5160

Y

Y

IBX

Anti PD-1/PD-L1 Human Monoclonal Antibodies

Loqtorzi™

J3263

Y

Y

IBX

Camrelizumab

J3490, J3590, C9399

Y

Y

IBX

Keytruda Qlex®

J3590, C9399

Y

Y

IBX

Tecentriq™

J9022

Y

Y

IBX

Bavencio®

J9023

Y

Y

IBX

Tecentriq Hybreza™

J9024

Y

Y

IBX

Libtayo®

J9119

Y

Y

IBX

Imfinzi™

J9173

Y

Y

IBX

Keytruda™

J9271

Y

Y

IBX

Jemperli™

J9272

Y

Y

IBX

Unloxcyt™

J9275

Y

Y

IBX

Opdivo Qvantig™

J9289

Y

Y

IBX

Opdivo®

J9299

Y

Y

IBX

Tevimbra®

J9329

Y

Y

IBX

Zynyz™

J9345

Y

Y

IBX

Bone-Modifying Agents

Enoby®

C9399

Y

Y

IBX

Prolia®

J0897

Y

Y

IBX

Xgeva®

J0897

Y

Y

IBX

Evenity™

J3111

Y

Y

IBX

Enoby®

J3590

Y

Y

IBX

Xtrenbo®

J3590, C9399

Y

Y

IBX

Aukelso®

J3590, C9399

Y

Y

IBX

Bildyos®

J3590, C9399

Y

Y

IBX

Bilprevda®

J3590, C9399

Y

Y

IBX

Bosaya®

J3590, C9399

Y

Y

IBX

Osenvelt®

Q5157

Y

Y

IBX

Bomyntra®

Q5158

Y

Y

IBX

Conexxance®

Q5158

Y

Y

IBX

Ospomyv™

Q5159

Y

Y

IBX

Botulinum Toxin Agents

Botox®

J0585

Y

Y

IBX

Chimeric Antigen Receptor (CAR-T) Therapies

Yescarta™

Q2041

Y

Y

IBX

Kymriah™

Q2042

Y

Y

IBX

Tecartus™

Q2053

Y

Y

IBX

Breyanzi®

Q2054

Y

Y

IBX

Abecma®

Q2055

Y

Y

IBX

Carvykti™

Q2056

Y

Y

IBX

Aucatzyl®

Q2058

Y

Y

IBX

Duchenne Muscular Dystrophy

Amondys 45

J1426

Y

Y

IBX

Exondys 51

J1428

Y

Y

IBX

Vyondys 53

J1429

Y

Y

IBX

Endocrine/Metabolic Agents

Lutathera®

A9513

Y

Y

eviCore

Xenpozyme®

J0218

Y

Y

IBX

Acthar® Gel

J0801

Y

Y

IBX

Cortrophin® Gel

J0802

Y

Y

IBX

Somatuline® Depot

J1930

Y

Y

IBX

Lanreotide

J1932

Y

Y

IBX

Sandostatin® LAR

J2353

Y

Y

IBX

Enzyme Replacement Agents

Fabrazyme®

J0180

Y

Y

IBX

Lamzede®

J0217

Y

Y

IBX

Nexviazyme™

J0219

Y

Y

IBX

Lumizyme®

J0221

Y

Y

IBX

Brineura™

J0567

Y

Y

IBX

Pombiliti™

J1203

Y

Y

IBX

Vimizim™

J1322

Y

Y

IBX

Naglazyme®

J1458

Y

Y

IBX

Elaprase®

J1743

Y

Y

IBX

Cerezyme®

J1786

Y

Y

IBX

Aldurazyme®

J1931

Y

Y

IBX

Elfabrio®

J2508

Y

Y

IBX

Kanuma®

J2840

Y

Y

IBX

Elelyso®

J3060

Y

Y

IBX

Vpriv®

J3385

Y

Y

IBX

Mepsevii™

J3397

Y

Y

IBX

Replagal®

J3490

Y

Y

IBX

Tividenofusp alfa

J3490, J3590, C9399

Y

Y

IBX

Revcovi™

J3590, C9399

Y

Y

IBX

Adzynma

J7171

Y

Y

IBX

Gene Replacement / Gene Editing Therapies

Hemgenix®

J1411

Y

Y

IBX

Roctavian

J1412

Y

Y

IBX

Elevidys®

J1413

Y

Y

IBX

Skysona®

J3387

Y

Y

IBX

Lenmeldy™

J3391

Y

Y

IBX

Casgevy™

J3392

Y

Y

IBX

Zynteglo®

J3393

Y

Y

IBX

Lyfgenia™

J3394

Y

Y

IBX

Luxturna™

J3398

Y

Y

IBX

Zolgensma®

J3399

Y

Y

IBX

Vvjuvek™

J3401

Y

Y

IBX

Clemidsogene lanparvovec

J3490, J3590, C9399

Y

Y

IBX

Eladocagene exuparvovec

J3490, J3590, C9399

Y

Y

IBX

Etuvetidigene autotemcel

J3490, J3590, C9399

Y

Y

IBX

Marnetegragene aututemcel

J3490, J3590, C9399

Y

Y

IBX

Itvisma®

J3590, C9399

Y

Y

IBX

Papzimeos®

J3590, C9399

Y

Y

IBX

Zevaskyn®

J3389

Y

Y

IBX

Hemophilia/Coagulation Factors

Hemlibra®

J7170

Y

Y

IBX

Hympavzi™

J7172

Y

Y

IBX

Alhemo®

J7173

Y

Y

IBX

Qfitlia™

J7174

Y

Y

IBX

Coagadex®

J7175

Y

Y

IBX

Fibryga®

J7177

Y

Y

IBX

RiaSTAP®

J7178

Y

Y

IBX

Vonvendi®

J7179

Y

Y

IBX

Corifact®

J7180

Y

Y

IBX

Tretten®

J7181

Y

Y

IBX

Novoeight®

J7182

Y

Y

IBX

Wilate®

J7183

Y

Y

IBX

Xyntha®

J7185

Y

Y

IBX

Alphanate®

J7186

Y

Y

IBX

Humate-P®

J7187

Y

Y

IBX

Obizur®

J7188

Y

Y

IBX

Novoseven RT®

J7189

Y

Y

IBX

Novoseven®

J7189

Y

Y

IBX

Hemofil-M®

J7190

Y

Y

IBX

Koate-DVI®

J7190

Y

Y

IBX

Monoclate-P®

J7190

Y

Y

IBX

Advate®

J7192

Y

Y

IBX

Helixate FS®

J7192

Y

Y

IBX

Kogenate FS®

J7192

Y

Y

IBX

Recombinate®

J7192

Y

Y

IBX

Alphanine SD®

J7193

Y

Y

IBX

Mononine®

J7193

Y

Y

IBX

Bebulin VH®

J7194

Y

Y

IBX

Profilnine SD®

J7194

Y

Y

IBX

Benefix®

J7195

Y

Y

IBX

Feiba NF®

J7198

Y

Y

IBX

Feiba VH®

J7198

Y

Y

IBX

Vonvendi®

J7199

Y

Y

IBX

Rixubis®

J7200

Y

Y

IBX

Alprolix®

J7201

Y

Y

IBX

Idelvion®

J7202

Y

Y

IBX

Rebinyn®

J7203

Y

Y

IBX

Esperoct®

J7204

Y

Y

IBX

Eloctate®

J7205

Y

Y

IBX

Adynovate®

J7207

Y

Y

IBX

Jivi®

J7208

Y

Y

IBX

Nuwiq®

J7209

Y

Y

IBX

Afstyla®

J7210

Y

Y

IBX

Kovaltry®

J7211

Y

Y

IBX

Sevenfact®

J7212

Y

Y

IBX

Ixinity®

J7213

Y

Y

IBX

Altuviiio®

J7214

Y

Y

IBX

Hyaluronate Acid Products

Cingal

J3490

Y

Y

IBX

Durolane®

J7318

Y

Y

IBX

GenVisc 850®

J7320

Y

Y

IBX

Hyalgan®

J7321

Y

Y

IBX

Supartz®

J7321

Y

Y

IBX

VISCO-3®

J7321

Y

Y

IBX

Hymovis®

J7322

Y

Y

IBX

Euflexxa™

J7323

Y

Y

IBX

Gel-One®

J7326

Y

Y

IBX

Gelsyn-3™

J7328

Y

Y

IBX

TriVisc™

J7329

Y

Y

IBX

Synojoynt™

J7331

Y

Y

IBX

Triluron™

J7332

Y

Y

IBX

Immunological Agents

Orencia® IV

J0129

Y

Y

IBX

Benlysta® IV

J0490

Y

Y

IBX

Saphnelo™

J0491

Y

Y

IBX

Simponi® Aria

J1602

Y

Y

IBX

Tremfya® IV

J1628

Y

Y

IBX

Spevigo®

J1747

Y

Y

IBX

Omvoh™

J2267

Y

Y

IBX

Skyrizi® IV

J2327

Y

Y

IBX

Ilumya™

J3245

Y

Y

IBX

Cosentyx® IV

J3247

Y

Y

IBX

Actemra®

J3262

Y

Y

IBX

Stelara®

J3357

Y

N

IBX

Stelara®

J3358

Y

Y

IBX

Entyvio™

J3380

Y

Y

IBX

Starjemza®

J3590, C9399

Y

Y

IBX

Imuldosa®

Q5098

Y

Y

IBX

Steqeyma®

Q5099

Y

Y

IBX

Yesintek™

Q5100

Y

Y

IBX

Tofidence™

Q5133

Y

Y

IBX

Tyenne®

Q5135

Y

Y

IBX

Wezlana

Q5137

Y

Y

IBX

Wezlana

Q5138

Y

Y

IBX

Avtozma®

Q5156

Y

Y

IBX

Pyzchiva®

Q9996

Y

Y

IBX

Pyzchiva®

Q9997

Y

Y

IBX