Skip to content
Navigated to 2021 Prior Authorization List for Medicare Part B Drugs page

2021 Prior Authorization List for Medicare Part B Drugs


Providers: For the quickest turnaround on prior authorizations, use Availity. You can find the login link and instructions in the "Using Availity" section of our Providers page.

Members: Your provider usually handles prior authorizations for you. If you need any help, call us at 1-800-338-6833, TTY 711.

For each drug, we provide the billing code, generic name, and brand name as follows:

Billing code generic name (BRAND NAME)

A Codes

A9513 lutetium Lu 177 dotatate (LUTATHERA)

A9517 Iodine i-131 sodium iodide capsule(s)

A9530 I131 iodide

A9543 Y90 ibritumomab (ZEVALIN)

A9600 strontium-89 chloride (METASTRON)

A9604 samarium Sm 153 lexidronam (QUADRAMET)

A9606 radium-223 dichloride (XOFIGO)

A9699 radiopharmaceutical, therapeutic, not otherwise classified

C Codes

C9061 teprotumumab-trbw (TEPEZZA)

C9062 daratumumab, hyaluronidase (DARZALEX FASPRO)

C9063 eptinezumab-jjmr (VYEPTI)

C9064 mytomycin (JELMYTO)

C9066 sacituzumab govitecan-hziy (TRODELVY)

C9075 casimersen (AMONDYS 45)

C9076 lisocabtagene maraleucel (BREYANZI)

C9077 cabotegravir and rilpivirine (CABENUVA)

C9078 trilaciclib (COSELA)

C9079 evinacumab-dgnb (EVKEEZA)

C9080 melphalan flufenamide (PEPAXTO)

C9257 bevacizumab

C9399 Unclassified drugs or biologicals

C9467 rituximab and hyaluronidase (RITUXAN HYCELA)

J Codes

J0129 abatacept (ORENCIA)

J0178 aflibercept (EYLEA)

J0179 brolucizumab-dbll (BEOVU)

J0180 agalsidase beta (FIBRAZYME)

J0185 aprepitant (CINVANTI)

J0202 alemtuzumab (LEMTRADA)

J0207 amifostine (ETHYOL)

J0221 alglucosidase alfa (LUMIZYME)

J0222 patisiran (ONPATTRO)

J0223 givosiran (GIVLAARI)

J0224 lumasiran (OXLUMO)

J0256 human alpha 1-proteinase inhibitor (PROLASTIN C, ARALAST NP, ZEMARIA)

J0257 human alpha 1-proteinase inhibitor (GLASSIA)

J0485 belatacept (NULOJIX)

J0490 belimumab (BENLYSTA)

J0517 benralizumab (FASENRA)

J0565 bezlotoxumab (ZINPLAVA)

J0567 cerliponase alfa (BRINEURA)

J0584 burosumab-twza (CRYSVITA)

J0585 onabotulinumtoxinA (BOTOX)

J0586 abobotulinumtoxinA (DYSPORT)

J0587 rimabotulinumtoxinB (MYOBLOC)

J0588 incobotulinumtoxinA (XEOMIN)

J0591 deoxycholic acid (KYBELLA)

J0593 lanadelumab-flyo (TAKHZYRO)

J0594 busulfan (BUSULFEX)

J0596 recombinant C1 esterase inhibitor (RUCONEST)

J0597 human C1 esterase inhibitor (BERINERT)

J0598 human C1 esterase inhibitor (CINRYZE)

J0599 human C1 esterase inhibitor (HAEGARDA)

J0600 edetate calcium disodium, calcium EDTA

J0630 salmon calcitonin (MIACALCIN)

J0638 canakinumab (ILARIS)

J0640 leucovorin calcium

J0641 levoleucovorin (FUSILEV, KHAPZORY)

J0642 levoleucovorin (KHAPZORY)

J0717 certolizumab pegol (CIMZIA)

J0775 collagenase, clostridium histolyticum (XIAFLEX)

J0791 crizanlizumab-tmca (ADAKVEO)

J0800 corticotropin, ACTH (H.P. ACTHAR GEL)

J0850 human cytomegalovirus immune globulin intravenous (CYTOGAM)

J0881 darbepoetin alfa for non-esrd use (ARANESP)

J0882 darbepoetin alfa for esrd on dialysis (ARANESP)

J0885 epoetin alfa (EPOGEN/PROCRIT) for non-ESRD use

J0886 epoetin alfa (EPOGEN/PROCRIT) for ESRD on dialysis

J0887 epoetin beta (MIRCERA) for ESRD use 

J0888 epoetin beta (MIRCERA) for non-ESRD use

J0894 decitabine

J0896 luspatercept-aamt (REBLOZYL)

J0897 denosumab (PROLIA, XGEVA)

J1190 dexrazoxane hydrochloride (ZINECARD)

J1260 dolasetron (ANZEMET)

J1290 ecallantide (KALBITOR)

J1300 eculizumab (SOLIRIS)

J1301 edaravone (RADICAVA)

J1303 ravulizumab-cwvz (ULTOMIRIS)

J1322 elosulfase alfa (VIMIZIM)

J1325 epoprostenol (FLOLAN, VELETRI)

J1427 viltolarsen (VILTEPSO)

J1428 eteplirsen (EXONDYS)

J1429 golodiresen (VYONDYS 53)

J1442 filgrastim (NEUPOGEN)

J1446 tbo-filgrastim (GRANIX) 

J1447 tbo-filgrastim (GRANIX)

J1453 fosaprepitant (EMEND)

J1454 fosnetupitant, palonosetron (AKYNZEO)

J1458 galsulfase (NAGLAZYME)

J1459 immune globulin (PRIVIGEN)

J1460 immune globulin

J1554 mmune globulin (ASCENIV)

J1555 immune globulin (CUVITRU)

J1556 immune globulin (BIVIGAM)

J1557 immune globulin (GAMMAPLEX)

J1558 immune globulin (XEMBIFY)

J1559 immune globulin (HIZENTRA)

J1560 immune globulin

J1561 immune globulin (GAMUNEX, GAMUNEX-C, GAMMAKED)

J1562 immune globulin (VIVAGLOBULIN)

J1566 immune globulin

J1568 immune globulin (OCTAGAM)

J1569 immune globulin (GAMMAGARD)

J1572 immune globulin (FLEBOGAMMA, FLEBOGAMMA DIF)

J1575 recombinant hyaluronidase, immune globulin (HYQVIA)

J1599 immune globulin

J1602 golimumab (SIMPONI)

J1626 granisetron (KYTRIL)

J1627 extended-release granisetron (SUSTOL)

J1628 guselkumab (TREMFYA)

J1632 brexanolone (ZULRESSO)

J1640 hemin (PANHEMATIN)

J1743 idursulfase (ELAPRASE)

J1745 infliximab (REMICADE)

J1786 imiglucerase (CEREZYME)

J1930 lanreotide (SOMATULINE DEPOT)

J1931 laronidase (ALDURAZYME)

J1950 leuprolide acetate for depot suspension (LUPRON DEPOT)

J1951 leuprolide acetate for depot suspension (FENSOLVI)

J2182 mepolizumab (NUCALA)

J2323 natalizumab (TYSABRI)

J2326 nusinersen (SPINRAZA)

J2350 ocrelizumab (OCREVUS)

J2353 octreotide for depot suspension (SANDOSTATIN LAR)

J2354 octreotide non-depot (SANDOSTATIN)

J2357 omalizumab (XOLAIR)

J2425 palifermin (KEPIVANCE)

J2430 pamidronate disodium

J2469 palonosetron (ALOXI)

J2502 pasireotide (SIGNIFOR LAR)

J2503 pegaptanib sodium (MACUGEN)

J2505 pegfilgrastim (NEULASTA)

J2507 pegloticase (KRYSTEXXA)

J2562 plerixafor (MOZOBIL)

J2760 phentolamine mesylate (ORAVERSE)

J2778 ranibizumab (LUCENTIS)

J2783 rasburicase (ELITEK)

J2786 reslizumab (CINQAIR)

J2793 rilonacept (ARCALYST)

J2796 romiplostim (NPLATE)

J2797 rolapitant (VARUBI)

J2820 sargramostim (LEUKINE)

J2840 sebelipase alfa (KANUMA)

J2860 siltuximab (SYLVANT)

J3031 fremanezumab-vfrm (AJOVY)

J3032 eptinezumab-jjmr (VYEPTI)

J3060 taliglucerase alpha (ELELYSO)

J3111 romosozumab-aqqg (EVENITY)

J3240 thyrotropin alpha (THYROGEN)

J3241 teprotumumab-trbw (TEPEZZA)

J3245 tildrakizumab (ILUMYA)

J3262 tocilizumab (ACTEMRA)

J3285 treprostinil (REMODULIN)

J3315 triptorelin pamoate (TRELSTAR)

J3316 extended-release triptorelin (TRELSTAR, TRIPTODUR)

J3357 ustekinumab (STELARA)

J3358 ustekinumab (STELARA)

J3380 vedolizumab (ENTYVIO)

J3385 velaglucerase alfa (VPRIV)

J3396 verteporfin (VISUDYNE)

J3397 vestronidase alfa-vjbk (MEPSEVII)

J3398 voretigene neparvovec-rzyl (LUXTURNA)

J3399 onasemnogene abeparvovec-xioi (ZOLGENSMA)

J3489 zoledronic acid (ZOMETA)

J3590 Unclassified biologics

J3591 Unclassified drug or biological used for ESRD on dialysis

J7168 prothrombin complex concentrate (human) (KCENTRA)

J7169 coagulation factor Xa (recombinant), inactivated-zhzo (ANDEXXA)

J7170 emicizumab-kxwh (HEMLIBRA)

J7175 human coagulation factor X (COAGADEX)

J7177 human fibrinogen concentrate (FIBRYGA)

J7178 human fibrinogen concentrate

J7179 recombinant von Willebrand factor (VONVENDI)

J7180 human factor XIII concentrate (CORIFACT)

J7181 recombinant coagulation factor XIII A-subunit (TRETTEN)

J7182 turoctocog alfa (NOVOEIGHT)

J7183 von Willebrand factor, human coagulation factor VIII complex (WILATE)

J7185 recombinant antihemophilic factor (XYNTHA)

J7186 antihemophilic factor, human von Willebrand factor complex (ALPHANATE)

J7187 antihemophilic factor, human von Willebrand factor complex (HUMATE-P)

J7188 recombinant antihemophilic factor, porcine sequence (OBIZUR)

J7189 recombinant coagulation factor VIIa (NOVOSEVEN RT)

J7190 human antihemophilic factor (KOATE-DVI)

J7191 porcine antihemophilic factor

J7192 recombinant antihemophilic factor (ADVATE)

J7193 human coagulation factor IX (ALPHANINE SD)

J7194 factor IX complex (BEBULIN)

J7195 recombinant coagulation factor IX (BENEFIX)

J7196 recombinant antithrombin

J7197 human antithrombin III (THROMBATE III)

J7198 anti-inhibitor coagulant complex (FEIBA NF)

J7199 Hemophilia clotting factor, not otherwise classified

J7200 recombinant coagulation factor IX (RIXUBIS)

J7201 recombinant coagulation factor IX (ALPROLIX)

J7202 recombinant antihemophilic factor (IDELVION)

J7203 recombinant glycopegalated coagulation factor IX (REBINYN)

J7204 glycopegylated-exei factor VIII (ESPEROCT)

J7205 recombinant antihemophilic factor, Fc fusion protein (ELOCTATE)

J7207 recombinant pegylated antihemophilic factor (ADYNOVATE)

J7208 pegylated lyophilisate antihemophilic factor (JIVI)

J7209 simoctocog alfa (NUWIQ)

J7210 recombinant antihemophilic factor single chain (AFSTYLA)

J7211 recombinant antihemophilic factor (KOVALTRY)

J7212 recombinant coagulation factor VIIa - jncw (SEVENFACT)

J7313 fluocinolone acetonide (ILUVIEN)

J7318 hyaluronate sodium (DUROLANE)

J7320 hyaluronate sodium (GENVISC)

J7321 hyaluronate sodium (HYALGAN, SUPARTZ, VISCO-3)

J7322 hyaluronic acid (HYMOVIS)

J7323 hyaluronate sodium (EUFLEXXA)

J7324 hyaluronate sodium (ORTHOVISC)

J7325 avian hylan (SYNVISC, SYNVISC-ONE)

J7326 hyaluronate sodium (GEL-ONE)

J7327 hyaluronate sodium (MONOVISC)

J7328 hyaluronate sodium (GELSYN)

J7329 hyaluronate sodium (TRIVISC)

J7331 hyaluronate sodium (SYNOJOINT)

J7332 hyaluronate sodium (TRILURON)

J7351 bimatoprost (DURYSTA INTRAOCULAR)

J7352 afamelanotide (SCENESSE)

J7402 mometasone furoate sinus implant (SINUVA)

J7504 lymphocyte immune globulin, antithymocyte, equ/thimerosal (ATGAM)

J7639 dornase alfa (PULMOZYME)

J7686 treprostinil (TYVASO)

J7799 NOC drugs, other than inhalation drugs, administered through DME

J8498 Antiemetic drug, rectal/suppository, not otherwise specified

J8501 aprepitant (EMEND)

J8510 busulfan (MYLERAN)

J8520 capecitabine (XELODA)

J8521 capecitabine (XELODA)

J8530 cyclophosphamide (CYTOXAN)

J8560 etoposide (VEPESID)

J8597 Antiemetic drug, oral, not otherwise specified

J8600 melphalan (MELPHALAN)

J8610 methotrexate (TREXALL)

J8655 netupitant, palonosetron (AKYNZEO)

J8670 rolapitant (VARUBI)

J8700 temozolomide

J8705 topotecan (HYCAMTIN)

J8999 Prescription drug, oral, chemotherapeutic, NOS

J9000 doxorubicin (ADRIAMYCIN)

J9015 aldesleukin (PROLEUKIN)

J9017 arsenic trioxide (TRISENOX)

J9019 asparaginase - Erwinia chrysanthemi (ERWINAZE)

J9020 asparaginase

J9022 atezolizumab (TECENTRIQ)

J9023 avelumab (BAVENCIO)

J9025 azacitidine (VIDAZA)

J9027 clofarabine (CLOLAR)

J9030 BCG Live (TICE BCG LIVE, THERACYS)

J9032 belinostat (BELEODAQ)

J9033 bendamustine (TREANDA)

J9034 bendamustine (BENDEKA)

J9035 bevacizumab (AVASTIN)

J9036 bendamustine hydrochloride (BELPRAZO, BENDAMUSTINE)

J9037 belantamab mafodontin-blmf (BLENREP)

J9039 blinatumomab (BLINCYTO)

J9040 bleomycin sulfate (BLENOXANE, BLEO 15K)

J9041 bortezomib (VELCADE)

J9042 brentuximab vedotin (ADCETRIS)

J9043 cabazitaxel (JEVTANA)

J9044 bortezomib

J9045 carboplatin (PARAPLATIN)

J9047 carfilzomib (KYPROLIS)

J9050 carmustine (BICNU)

J9055 cetuximab (ERBITUX)

J9057 copanlisib (ALIQOPA)

J9060 cisplatin (PLATINOL, PLATINOL AQ)

J9065 cladribine (LEUSTATIN)

J9070 cyclophosphamide (CYTOXAN, NEOSAR)

J9098 cytarabine liposomal (DEPCYT)

J9100 cytarabine (CYTOSAR U)

J9118 calaspargase pegol-mknl (ASPARLAS)

J9119 cemiplimab-rwlc (LIBTAYO)

J9120 dactinomycin (COSMEGEN)

J9130 dacarbazine (DTIC-DOME)

J9144 daratumumab and hyaluronidase-fihj (DARZALEX FASPRO)

J9145 daratumumab (DARZALEX)

J9150 daunorubicin (CERUBIDINE)

J9151 liposomal daunorubicin (DAUNOXOME)

J9153 liposomal daunorubicin, liposomal cytarabine (VYXEOS)

J9155 degarelix (FIRMAGON)

J9160 denileukin diftitox (ONTAK)

J9165 diethylstilbestrol (STILPHOSTORL)

J9171 docetaxel (TAXOTERE)

J9173 durvalumab (IMFINZI)

J9175 Injection, Elliotts B solution, 1 ml (Elliotts B Solution)

J9176 elotuzumab (EMPLICITI)

J9177 enfortumab vendotin-ejfv (PADCEV)

J9178 epirubicin (ELLENCE)

J9179 eribulin (HALAVEN)

J9181 etoposide (ETOPOPHOS, TOPOSAR, VEPESID)

J9185 fludarabine (FLUDARA)

J9190 fluorouracil (ADRUCIL)

J9198 gemcitabine hydrochloride (INFUGEM)

J9200 floxuridine (FUDR)

J9201 gemcitabine (GEMZAR)

J9202 goserelin (ZOLADEX)

J9203 gemtuzumab ozogamicin (MYLOTARG)

J9204 mogamulizumab-kpkc (POTELIGEO)

J9205 liposomal irinotecan (ONIVYDE)

J9206 irinotecan (CAMPTOSAR)

J9207 ixabepilone (IXEMPRA)

J9208 ifosfamide (IFEX)

J9209 mesna (MESNEX)

J9210 emapalumab-lzsg (GAMIFANT)

J9211 idarubicin (IDAMYCIN)

J9214 recombinant interferon alfa-2b (INTRON A)

J9215 human-leukocyte-derived interferon alfa-N3 (ALFERON N)

J9216 interferon gamma-1b, recomb. (ACTIMMUNE)

J9217 leuprolide acetate (for depot suspension) (LUPRON)

J9218 leuprolide acetate (LUPRON)

J9219 leuprolide acetate for implant (VIADUR)

J9223 lurbinectedin (ZEPZELCA)

J9225 histrelin (VANTAS)

J9226 histrelin (SUPPRELIN LA)

J9227 isatuximab-irfc (SARCLISA)

J9228 ipilimumab (YERVOY)

J9229 inotuzumab ozogamicin (BESPONSA)

J9230 mechlorethamine (MUSTARGEN)

J9245 melphalan, not otherwise specified (ALKERAN)

J9246 melphalan (EVOMELA)

J9250 methotrexate

J9260 methotrexate

J9261 nelarabine (ARRANON)

J9262 omacetaxine (SYNRIBO)

J9263 oxaliplatin (ELOXATIN)

J9264 albumin-bound paclitaxel (ABRAXANE)

J9266 pegaspargase (ONCASPAR)

J9267 paclitaxel (ONXOL, TAXOL)

J9268 pentostatin (NIPENT)

J9269 tagraxofusp-erzs (ELZONRIS)

J9270 plicamycin (MITHRACIN)

J9271 pembrolizumab (KEYTRUDA)

J9280 mitomycin (MUTAMYCIN)

J9281 mitomycin pyelocalyceal instillation (JELMYTO)

J9285 olaratumab (LARTRUVO)

J9293 mitoxantrone (NOVANTRONE)

J9295 necitumumab (PORTRAZZA)

J9299 nivolumab (OPDIVO)

J9301 obinutuzumab (GAZYVA)

J9302 ofatumumab (ARZERRA)

J9303 panitumumab (VECTIBIX)

J9304 pemetrexed (PEMFEXY)

J9305 pemetrexed, not otherwise specified (ALIMTA)

J9306 pertuzumab (PERJETA)

J9307 pralatrexate (FOLOTYN)

J9308 ramucirumab (CYRAMZA)

J9309 polatuzumab vendotin-piiq

J9310 rituximab (RITUXAN)

J9311 rituximab, hyaluronidase (RITUXAN HYCELA)

J9312 rituximab (RITUXAN)

J9313 moxetumomab pasudotox-tdfk (LUMOXITI)

J9314 romidepsin, nonlyophilized (ISTODAX)

J9315 romidepsin (ISTODAX)

J9316 pertuzumab, trastuzumab, and hyaluronidase-zzxf (PHESGO)

J9317 sacituzumab govitecan-hziy (TRODELVY)

J9320 streptozocin (ZANOSAR)

J9325 talimogene laherparepvec (IMLYGIC)

J9328 temozolomide (TEMODAR)

J9330 temsirolimus (TORISEL)

J9340 thiotepa (TEPADINA)

J9348 naxitamab-gqgk (DANYELZA)

J9349 tafasitamab-cxix (MONJUVI)

J9351 topotecan (HYCAMTIN)

J9352 trabectedin (YONDELIS)

J9353 margetuximab-cmkb (MARGENZA)

J9354 ado-trastuzumab emtansine (KADCYLA)

J9355 trastuzumab (HERCEPTIN)

J9356 trastuzumab and hyaluronidase-oysk (HERCEPTIN HYLECTA)

J9357 valrubicin (VALSTAR)

J9358 fam-trastuzumab deruxtecan-nxki (ENHERTU)

J9360 vinblastine (VELBAN)

J9370 vincristine (ONCOVIN)

J9371 liposomal vincristine (MARQIBO)

J9390 vinorelbine (NAVELBINE)

J9395 fulvestrant (FASLODEX)

J9400 ziv-aflibercept (ZALTRAP)

J9600 porfimer (PHOTOFRIN)

J9999 Not-otherwise-classified antineoplastic drugs

M Codes

M0244 casirivimab and imdevimab (REGEN-COV)

M0246 bamlanivimab and etesevimab

Q Codes

Q0166 granisetron hydrochloride (KYTRIL)

Q0167 dronabinol (SYNDROS)

Q0180 dolasetron mesylate (ANZEMET)

Q2017 teniposide (VUMON)

Q2041 axicabtagene ciloleucel (YESCARTA)

Q2042 tisagenlecleucel (KYMRIAH)

Q2043 sipuleucel-T (PROVENGE)

Q2049 liposomal doxorubicin hydrochloride (LIPODOX, DOXIL)

Q2050 liposomal doxorubicin hydrochloride (LIPODOX, DOXIL)

Q2053 brexucabtagene autoleucel (TECARTUS)

Q3027 interferon beta-1a (AVONEX)

Q3028 interferon beta-1a (REBIF)

Q4074 iloprost (VENTAVIS)

Q4081 epoetin alfa (EPOGEN/PROCRIT) for ESRD on dialysis

Q5101 filgrastim-sndz, biosimilar (ZARXIO)

Q5102 infliximab, biosimilar

Q5103 infliximab-dyyb, biosimilar (INFLECTRA)

Q5104 infliximab-abda, biosimilar (RENFLEXIS)

Q5105 epoetin alfa-epbx, biosimilar for esrd on dialysis (RETACRIT)

Q5106 epoetin alfa-epbx, biosimilar for non-esrd use (RETACRIT)

Q5107 bevacizumab-awwb (MVASI)

Q5108 pegfilgrastim-jmdb (FULPHILA)

Q5109 infliximab-qbtx, biosimilar (IXIFI)

Q5110 filgrastim-aafi, biosimilar (NIVESTYM)

Q5111 pegfilgrastim-cbqv (UDENYCA)

Q5112 trastuzumab-dttb, biosimilar (ONTRUZANT)

Q5113 trastuzumab-pkrb, biosimilar (HERZUMA)

Q5114 trastuzumab-dkst (OGIVRI)

Q5115 rituximab-abbs (TRUXIMA)

Q5116 trastuzumab-qyyp (TRAZIMERA)

Q5117 trastuzumab-anns (KANJINTI)

Q5118 bevacizumab-bvcr (ZIRABEV)

Q5119 rituximab-pvvr (RUXIENCE)

Q5120 pegfilgrastim-bmez, biosimilar (ZIEXTENZO)

Q5121 infliximab-axxq, biosimilar (AVSOLA)

Q5123 rituximab-arrx (RIABNI)

Q9972 epoetin beta for esrd on dialysis

Q9973 epoetin beta for non-esrd use

S Codes

S0145 Peginterferon Alfa-2A (PEGASYS)

S0148 Peginterferon Alfa-2B (PEGINTRON)