2024 Prior Authorization List for Medicare Part B Drugs

Providers: For the quickest turnaround on prior authorizations, use Availity. You can find instructions on our prior authorizations 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

A9517 Iodine i-131 sodium iodide capsule(s)

A9600 strontium-89 chloride (METASTRON)

A9604 samarium Sm 153 lexidronam (QUADRAMET)

A9607 Lutetium lu 177 vipivotide (PLUVICTO)

A9699 radiopharmaceutical, therapeutic, not otherwise classified

C Codes

C9036 patisiran (ONPATTRO)

C9058 pegfilgrastim-bmez, biosimilar (ZIEXTENZO)

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)

C9081 idecabtagene vicleucel (ABECMA)

C9082 dostarlimab-gxly (JEMPERLI)

C9083 amivantamab-vmjw (RYBREVANT)

C9084 loncastuximab tesirine-lpyl (ZYNLONTA)

C9085 avalglucosidase alfa-ngpt (NEXVIAZYME)

C9086 anifrolumab-fnia (SAPHNELO)

C9087 cyclophosphamide (AUROMEDICS)

C9145 aprepitant (APONVIE)

C9166 secukinumab (COSENTYX)

C9167 apadamtase alfa (ADZYNMA)

C9168 mirikizumab-mrkz (OMVOH)

C9169 nogapendekin alfa inbakicept-pmln (ANKTIVA)

C9170 tarlatamab-dlle (IMDELLTRA)

C9172 fidanacogene elaparvovec-dzkt (BEQVEZ)

C9257 bevacizumab

C9399 Unclassified drugs or biologicals

C9466 benralizumab (FASENRA)

C9467 rituximab and hyaluronidase (RITUXAN HYCELA)

G Codes

G0138 cipaglucosidase alfa-atga with miglustat (POMBILITI)

J Codes

J0129 abatacept (ORENCIA)

J0172 aducanumab-avwa (ADUHELM)

J0174 lecanemab-irmb (LEQEMBI)

J0177 aflibercept (EYLEA HD)

J0178 aflibercept (EYLEA)

J0179 brolucizumab-dbll (BEOVU)

J0180 agalsidase beta (FIBRAZYME)

J0185 aprepitant (CINVANTI)

J0202 alemtuzumab (LEMTRADA)

J0206 allopurinol (ALOPRIM)

J0217 velmanase alfa-tycv (LAMZEDE)

J0218 olipudase alfa-rpcp (XENPOZYME)

J0219 avalglucosidase alfa-ngpt (NEXVIAZYME)

J0221 alglucosidase alfa (LUMIZYME)

J0222 patisiran (ONPATTRO)

J0223 givosiran (GIVLAARI)

J0224 lumasiran (OXLUMO)

J0225 vutrisiran (AMVUTTRA)

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

J0257 human alpha 1-proteinase inhibitor (GLASSIA)

J0485 belatacept (NULOJIX)

J0490 belimumab (BENLYSTA)

J0491 anifrolumab-fnia (SAPHNELO)

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)

J0589 daxibotulinumtoxina-lanm (DAXXIFY)

J0591 deoxycholic acid (KYBELLA)

J0593 lanadelumab-flyo (TAKHZYRO)

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)

J0641 levoleucovorin (FUSILEV, KHAPZORY)

J0642 levoleucovorin (KHAPZORY)

J0717 certolizumab pegol (CIMZIA)

J0739 cabotegravir (APRETUDE)

J0741 cabotegravir and rilpivirine (CABENUVA)

J0750 Emtricitabine and tenofovir disoproxil fumarate (TRUVADA)

J0751 Emtricitabine and tenofovir alafenamide (DESCOVY)

J0775 collagenase, clostridium histolyticum (XIAFLEX)

J0791 crizanlizumab-tmca (ADAKVEO)

J0799 FDA-approved prescription drug, only for use as HIV pre-exposure prophylaxis (not for use as treatment of HIV), not otherwise classified

J0801 corticotropin (ACTHAR GEL)

J0802 corticotropin (ANI)

J0879 difelikefalin (KORSUVA)

J0881 darbepoetin alfa (ARANESP) for non-ESRD use

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

J0888 epoetin beta (MIRCERA) for non-ESRD use

J0889 daprodustat (JESDUVROQ)

J0896 luspatercept-aamt (REBLOZYL)

J0897 denosumab (PROLIA, XGEVA)

J1203 cipaglucosidase alfa-atga (POMBILITI)

J1260 dolasetron (ANZEMET)

J1290 ecallantide (KALBITOR)

J1300 eculizumab (SOLIRIS)

J1301 edaravone (RADICAVA)

J1302 sutimlimab-jome (ENJAYMO)

J1303 ravulizumab-cwvz (ULTOMIRIS)

J1304 tofersen (QALSODY)

J1305 evinacumab-dgnb (EVKEEZA)

J1306 inclisiran (LEQVIO)

J1322 elosulfase alfa (VIMIZIM)

J1323 elranatamab-bcmm (ELREXFIO)

J1325 epoprostenol (FLOLAN, VELETRI)

J1411 etranacogene dezaparvovec-drlb (HEMGENIX)

J1412 valoctocogene roxaparvovec-rvox (ROCTAVIAN)

J1413 delandistrogene moxeparvovec-rokl (ELEVIDYS)

J1426 casimersen (AMONDYS 45)

J1427 viltolarsen (VILTEPSO)

J1428 eteplirsen (EXONDYS)

J1429 golodiresen (VYONDYS 53)

J1437 ferric derisomaltose (MONOFERRIC)

J1439 ferric carboxymaltose (INJECTAFER)

J1442 filgrastim (NEUPOGEN)

J1447 tbo-filgrastim (GRANIX)

J1448 trilaciclib (COSELA)

J1449 eflapegrastim-xnst (ROLVEDON)

J1454 fosnetupitant, palonosetron (AKYNZEO)

J1458 galsulfase (NAGLAZYME)

J1459 immune globulin (PRIVIGEN)

J1460 immune globulin

J1551 immune globulin (CUTAQUIG)

J1554 immune 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)

J1576 immune globulin (PANZYGA)

J1599 immune globulin

J1602 golimumab (SIMPONI)

J1627 extended-release granisetron (SUSTOL)

J1628 guselkumab (TREMFYA)

J1632 brexanolone (ZULRESSO)

J1640 hemin (PANHEMATIN)

J1743 idursulfase (ELAPRASE)

J1744 icatibant (FIRAZYR)

J1745 infliximab (REMICADE)

J1747 spesolimab-sbzo (SPEVIGO)

J1748 infliximab-dyyb (ZYMFENTRA)

J1786 imiglucerase (CEREZYME)

J1823 inebilizumab-cdon (UPLIZNA)

J1930 lanreotide (SOMATULINE DEPOT)

J1931 laronidase (ALDURAZYME)

J1932 lanreotide (CIPLA)

J1950 leuprolide acetate for depot suspension (LUPRON DEPOT)

J1951 leuprolide acetate for depot suspension (FENSOLVI)

J1952 leuprolide mesylate depot (CAMCEVI)

J1954 leuprolide acetate for depot suspension (CIPLA)

J1961 lenacapavir (SUNLENCA)

J2182 mepolizumab (NUCALA)

J2267 mirikizumab-mrkz (OMVOH)

J2277 motixafortide (APHEXDA)

J2323 natalizumab (TYSABRI)

J2326 nusinersen (SPINRAZA)

J2327 risankizumab-rzaa (SKYRIZI)

J2329 ublituximab-xiiy (BRIUMVI)

J2350 ocrelizumab (OCREVUS)

J2353 octreotide for depot suspension (SANDOSTATIN LAR)

J2354 octreotide non-depot (SANDOSTATIN)

J2356 tezepelumab-ekko (TEZSPIRE)

J2357 omalizumab (XOLAIR)

J2425 palifermin (KEPIVANCE)

J2430 pamidronate disodium

J2502 pasireotide (SIGNIFOR LAR)

J2503 pegaptanib sodium (MACUGEN)

J2505 pegfilgrastim (NEULASTA)

J2506 pegfilgrastim excludes biosimilars (all NEULASTA products)

J2507 pegloticase (KRYSTEXXA)

J2508 pegunigalsidase alfa-iwxj (ELFABRIO)

J2562 plerixafor (MOZOBIL)

J2760 phentolamine mesylate (ORAVERSE)

J2777 faricimab-svoa (VABYSMO)

J2778 ranibizumab (LUCENTIS)

J2779 ranibizumab, via sustained release intravitreal implant (SUSVIMO)

J2781 pegcetacoplan (EMPAVELI)

J2782 avacincaptad pegol (IZERVAY)

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)

J2998 plasminogen, human-tvmh (RYPLAZIM)

J3299 triamcinolone acetonide, suprachoroidal (XIPERE)

J3031 fremanezumab-vfrm (AJOVY)

J3032 eptinezumab-jjmr (VYEPTI)

J3055 talquetamab-tgvs (TALVEY)

J3060 taliglucerase alpha (ELELYSO)

J3111 romosozumab-aqqg (EVENITY)

J3241 teprotumumab-trbw (TEPEZZA)

J3245 tildrakizumab (ILUMYA)

J3247 secukinumab (COSENTYX)

J3262 tocilizumab (ACTEMRA)

J3263 toripalimab-tpzi (LOQTORZI)

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)

J3393 betibeglogene autotemcel (ZYNTEGLO)

J3394 lovotibeglogene autotemcel (LYFGENIA)

J3396 verteporfin (VISUDYNE)

J3397 vestronidase alfa-vjbk (MEPSEVII)

J3398 voretigene neparvovec-rzyl (LUXTURNA)

J3399 onasemnogene abeparvovec-xioi (ZOLGENSMA)

J3401 Beremagene geperpavec-svdt (VYJUVEK)

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)

J7171 ADAMTS13, recombinant-krhn (ADZYNMA)

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)

J7213 coagulation factor IX, recombinant (IXINITY)

J7214 antihemophilic factor (recombinant) (ALTUVIIIO)

J7310 ganciclovir, long-acting implant (VITRASERT)

J7311 fluocinolone acetonide, intravitreal implant (RETISERT)

J7312 dexamethasone, intravitreal implant (OZURDEX)

J7313 fluocinolone acetonide (ILUVIEN)

J7314 fluocinolone acetonide, intravitreal implant (YUTIQ)

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)

J7333 hyaluronate sodium (VISCO-3)

J7340 carbidopa and levodopa (DUOPA ENTERAL)

J7351 bimatoprost (DURYSTA INTRAOCULAR)

J7352 afamelanotide (SCENESSE)

J7355 travoprost (iDose TR)

J7402 mometasone furoate sinus implant (SINUVA)

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

J8597 Antiemetic drug, oral, not otherwise specified

J8655 netupitant, palonosetron (AKYNZEO)

J8670 rolapitant (VARUBI)

J8999 Prescription drug, oral, chemotherapeutic, NOS

J9015 aldesleukin (PROLEUKIN)

J9019 asparaginase - Erwinia chrysanthemi (ERWINAZE)

J9020 asparaginase

J9021 asparaginase, recombinant (RYLAZE)

J9022 atezolizumab (TECENTRIQ)

J9023 avelumab (BAVENCIO)

J9029 nadofaragene firadenovec-vncg (ADSTILDRIN)

J9032 belinostat (BELEODAQ)

J9033 bendamustine (TREANDA)

J9034 bendamustine (BENDEKA)

J9035 bevacizumab (AVASTIN)

J9036 bendamustine hydrochloride (BELPRAZO, BENDAMUSTINE)

J9037 belantamab mafodotin-blmf (BLENREP)

J9039 blinatumomab (BLINCYTO)

J9041 bortezomib (VELCADE)

J9042 brentuximab vedotin (ADCETRIS)

J9043 cabazitaxel (JEVTANA)

J9046 bortezomib (VELCADE)

J9047 carfilzomib (KYPROLIS)

J9048 bortezomib (VELCADE)

J9049 bortezomib (VELCADE)

J9051 bortezomib

J9055 cetuximab (ERBITUX)

J9056 bendamustine

J9057 copanlisib (ALIQOPA)

J9058 bendamustine

J9059 bendamustine

J9061 amivantamab-vmjw (RYBREVANT)

J9063 mirvetuximab soravtansine-gynx (ELAHERE)

J9064 cabazitaxel

J9098 cytarabine liposomal (DEPCYT)

J9118 calaspargase pegol-mknl (ASPARLAS)

J9119 cemiplimab-rwlc (LIBTAYO)

J9144 daratumumab and hyaluronidase-fihj (DARZALEX FASPRO)

J9145 daratumumab (DARZALEX)

J9151 liposomal daunorubicin (DAUNOXOME)

J9153 liposomal daunorubicin, liposomal cytarabine (VYXEOS)

J9155 degarelix (FIRMAGON)

J9165 diethylstilbestrol (STILPHOSTORL)

J9171 docetaxel (TAXOTERE)

J9172 docetaxel

J9173 durvalumab (IMFINZI)

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

J9176 elotuzumab (EMPLICITI)

J9177 enfortumab vendotin-ejfv (PADCEV)

J9179 eribulin (HALAVEN)

J9198 gemcitabine hydrochloride (INFUGEM)

J9202 goserelin (ZOLADEX)

J9203 gemtuzumab ozogamicin (MYLOTARG)

J9204 mogamulizumab-kpkc (POTELIGEO)

J9205 liposomal irinotecan (ONIVYDE)

J9207 ixabepilone (IXEMPRA)

J9210 emapalumab-lzsg (GAMIFANT)

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

J9217 leuprolide acetate for depot suspension (LUPRON)

J9218 leuprolide acetate (LUPRON)

J9219 leuprolide acetate for implant (VIADUR)

J9223 lurbinectedin (ZEPZELCA)

J9226 histrelin (SUPPRELIN LA)

J9227 isatuximab-irfc (SARCLISA)

J9228 ipilimumab (YERVOY)

J9229 inotuzumab ozogamicin (BESPONSA)

J9247 melphalan flufenamide (PEPAXTO)

J9258 paclitaxel protein-bound

J9259 paclitaxel protein-bound particles

J9261 nelarabine (ARRANON)

J9262 omacetaxine (SYNRIBO)

J9264 albumin-bound paclitaxel (ABRAXANE)

J9266 pegaspargase (ONCASPAR)

J9267 paclitaxel (ONXOL, TAXOL)

J9269 tagraxofusp-erzs (ELZONRIS)

J9270 plicamycin (MITHRACIN)

J9271 pembrolizumab (KEYTRUDA)

J9272 dostarlimab-gxly (JEMPERLI)

J9273 tisotumab vedotin-tftv (TIVDAK)

J9274 tebentafusp-tebn (KIMMTRAK)

J9285 olaratumab (LARTRUVO)

J9286 glofitamab-gxbm (COLUMVI)

J9294 pemetrexed

J9295 necitumumab (PORTRAZZA)

J9296 pemetrexed

J9297 pemetrexed

J9298 nivolumab and relatlimab-rmbw (OPDUALAG)

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 pemetrexed

J9315 romidepsin (ISTODAX)

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

J9317 sacituzumab govitecan-hziy (TRODELVY)

J9318 romidepsin, non-lyophilized (ISTODAX)

J9319 romidepsin, lyophilized (ISTODAX)

J9321 epcoritamab-bysp (EPKINLY)

J9322 pemetrexed

J9323 pemetrexed

J9324 pemetrexed

J9325 talimogene laherparepvec (IMLYGIC)

J9328 temozolomide (TEMODAR)

J9329 tislelizumab-jsgr (TEVIMBRA)

J9331 sirolimus, protein-bound (FYARRO)

J9332 efgartigimod alfa-fcab (VYVGART)

J9333 rozanolixizumab-noli (RYSTIGGO)

J9334 efgartigimod alfa and hyaluronidase-qvfc (VYVGART HYTRULO)

J9345 retifanlimab-dlwr (ZYNYZ)

J9347 tremelimumab-actl (IMJUDO)

J9348 naxitamab-gqgk (DANYELZA)

J9349 tafasitamab-cxix (MONJUVI)

J9350 mosunetuzumab-axgb (LUNSUMIO)

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)

J9359 loncastuximab tesirine-lpyl (ZYNLONTA)

J9361 efbemalenograstim alfa-vuxw (RYZNEUTA)

J9371 liposomal vincristine (MARQIBO)

J9376 pozelimab-bbfg (VEOPOZ)

J9380 teclistamab-cqyv (TECVAYLI)

J9381 teplizumab-mzwv (TZIELD)

J9400 ziv-aflibercept (ZALTRAP)

J9999 Not-otherwise-classified antineoplastic drugs

Q Codes

Q0138 ferumoxytol (FERAHEME)

Q0180 dolasetron mesylate (ANZEMET)

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)

Q2054 lisocabtagene maraleucel (BREYANZI)

Q2055 Idecabtagene vicleucel (ABECMA)

Q2056 Ciltacabtagene autoleucel (CARVYKTI)

Q3027 interferon beta-1a (AVONEX)

Q3028 interferon beta-1a (REBIF)

Q4074 iloprost (VENTAVIS)

Q5101 filgrastim-sndz, biosimilar (ZARXIO)

Q5102 infliximab, biosimilar

Q5103 infliximab-dyyb, biosimilar (INFLECTRA)

Q5104 infliximab-abda, biosimilar (RENFLEXIS)

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

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)

Q5122 pegfilgrastim-apgf biosimilar (NYVEPRIA)

Q5123 rituximab-arrx (RIABNI)

Q5124 ranibizumab-nuna (BYOOVIZ)

Q5125 filgrastim-ayow (RELEUKO)

Q5126 bevacizumab-maly (ALYMSYS)

Q5127 pegfilgrastim-fpgk (STIMUFEND)

Q5128 ranibizumab-eqrn (CIMERLI)

Q5129 bevacizumab-adcd (VEGZELMA)

Q5130 pegfilgrastim-pbbk (FYLNETRA)

Q5131 adalimumab-aacf (IDACIO)

Q5132 adalimumab-afzb (ABRILADA)

Q5133 tocilizumab-bavi (TOFIDENCE)

Q5134 natalizumab-sztn (TYRUKO)

Q5135 tocilizumab-aazg (TYENNE)

Q5136 denosumab-bbdz

Q5137 ustekinumab-auub (WEZLANA)

Q5138 ustekinumab-auub (WEZLANA)

S Codes

S0145 Peginterferon Alfa-2A (PEGASYS)

S0148 Peginterferon Alfa-2B (PEGINTRON)