January 1, 2024
The following revisions were incorporated into the January 1, 2024 update.
Additions
Reconstructive procedures and potentially cosmetic procedures Breast Reconstruction 19300 Genetically and bio-engineered skin substitutes for wound care Q4279 Q4287 Q4288 Q4289 Q4290 Q4291 Q4292 Q4293 Q4294 Q4295 Q4296 Q4297 Q4298 Q4299 Q4300 Q4301 Q4302 Q4303 Q4304
Prosthetics/orthoses Custom limb prosthetics including accessories/components L5615 L5926
Amyotrophic Lateral Sclerosis agents Debamestrocel (pending FDA approval) -
J3490, J3590, and C9399
Antineoplastic agents Columvi™ -
J9286 Elrexfio™ -
C9165, J3490, and J3590 Epkinly™ -
J9321 Pemfexy™ -
J9258 Talvey™ -
C9163, J3490, and J3590 Zolbetuximab (pending FDA approval) -
J3490, J3590, and C9399
Anti PD-1/PD-L1 human monoclonal antibodies Camrelizumab (pending FDA approval) -
J3490, J3590, and C9399 Cosibelimab (pending FDA approval) -
J3490, J3590, and C9399 Zynyz™ -
J9345
Endocrine/metabolic agents HCPCS J0801, Acthar® Gel, and HCPCS J0802, Ani, will only require precertification when
not appended with modifier JB.
Enzyme replacement agents Apadamtase Alfa (pending FDA approval) –
J3490, J3590, and C9399 Cinaxadamtase Alfa (pending FDA approval) –
J3490, J3590, and C9399 Elfabrio® -
J2508 Lamzede® - J0217
Gene Replacement / Gene Editing Therapies Casgevy™ –
J3490, J3590, and C9399 Elevidys® -
J1413 Fidanacogene Elaparvoec (pending FDA approval) –
J3490, J3590, and C9399 Lyfgenia™–
J3490, J3590, and C9399 Roctavian® -
J1412 Vvjuvek™ -
J3401
Multiple sclerosis agents Tyruko® -
J3490, J3590, and C9399
Myasthemia Gravis Agents Rystiggo® -
J9333 Vyvgart™ - J9332 Vyygart® Hytrulo -
J9334 (The Specialty Drugs requiring precertification section entitled “Myasthemia Gravis Agents" is a new section effective January 1, 2024.) Ophthalmic agents Eylea® HD -
J0178, J3590, and C9161
(Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
Tumor Infiltrating Lymphocyte (TIL) Therapy Lifileucel (pending FDA approval) –
J3490, J3590, and C9399 (The Specialty Drugs requiring precertification section entitled “Tumor Infiltrating Lymphocyte (TIL) Therapy" is a new section effective January 1, 2024.)
Miscellaneous therapeutic agents Lantidra® -
J3490, J3590, and C9399
Deletions
Prosthetics/orthoses Custom limb prosthetics including accessories/components K1014 K1022
Amyotrophic Lateral Sclerosis agents Radicava™ -
J1301 Qalsody™–
J3490, J3590, and C9399
Antineoplastic agents Alimta® -
J9305 Epkinly™ -
C9155 Kanjinti™ -
Q5117 Lumoxiti™ -
J9313 Mvasi™ -
Q5107
(Note: Ophthalmologic use of Mvasi does not require precertification.) Oportuzumab Monatox
(pending FDA approval) -
J3490, J3590, and C9399 Pemetrexed -
J9322, J9323 Pemfexy™ -
J9304, J9314, J9294, J9296, J9297 Ruxience™ -
Q5119 SH-111
(pending FDA approval) -
J3490, J3590, and C9399 Trazimera™ -
Q5116 Truxima™ -
Q5115 Zirabev™ - Q5118
(Note: Ophthalmologic use of Zirabev does not require precertification.) Zynyz™ -
J9345
Anti PD-1/PD-L1 human monoclonal antibodies Balstilimab (pending FDA approval) -
J3490, J3590, and C9399 Sintilimab
(pending FDA approval) -
J3490, J3590, and C9399 Zynyz™ -
J3590 and C9399
Chemotherapy-induced nausea and vomiting (CINV) agents Sustol® -
J1627 (The Specialty Drugs requiring precertification section entitled “Chemotherapy induced nausea and vomiting (CINV) agents" is removed effective January 1, 2024.)
Endocrine/metabolic agents Achtar H.P.® -
J0801 and J0802 Cosyntropin depot
(pending FDA approval) -
J3490, J3590, and C9399 Makena® -
J1726 and J1729
Enzyme replacement agents Lamzede® -
J3590
Gene Replacement / Gene Editing Therapies Roctavian™ -
J3590 and C9399 Vyjuvek™ -
J3590 and C9399
Neutropenia Neulasta® -
J2506
(Precertification requirements apply to all FDA-approved biosimilars to this reference product.) Neulasta Onpro™ -
J2506 Nivestym™ - Q5110 Nyvepria™ -
Q5122 Plinabulin
(pending FDA approval) -
J3490, J3590, and C9399
Ophthalmic agents Abicipar
(pending FDA approval) -
J3490, J3590, and C9399 Eylea® -
J0178
(Precertification requirements apply to all FDA-approved biosimilars to this reference product.) Eylea® HD –
J3590 and C9399
Pulmonary arterial hypertension Trevyent (pending FDA approval) -
J3490 and C9399
Respiratory agents Tezspire™ - J2356
Miscellaneous therapeutic agents Donislecel (pending FDA approval) -
J3490, J3590, and C9399 Vyvgart™ - J9332 Vyvgart® Hytrulo –
J3590 and C9399
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