Codes Requiring Prior Authorization Effective 1/23/2026

CANCER TREATMENT  

A9513

LUTETIUM LU 177 DOTATATE THERAPEUTIC 

1 MCI

C9155

INJECTION EPCORITAMAB-BYSP 

0.16

MG

C9163

INJECTION TALQUETAMAB-TGVS 

0.25

MG

C9165

INJECTION ELRANATAMAB-BCMM 

1 MG

J0202

INJECTION ALEMTUZUMAB 

1 MG

J0594

INJECTION BUSULFAN  

1 MG

J0640

INJ LEUCOVORIN CALCIUM PER  

50 MG

J0641

INJECTION LEVOLEUCOVORIN NOS  

0.5 MG

J0642

INJECTION, LEVOLEUCOVORIN (KHAPZORY)

0.5 mg

J0791

INJECTION CRIZANLIZUMAB-TMCA  

5 MG

J0893

INJECTION DECITABINE NOT THR EQUIV TO J0894  

1 MG

J0894

INJECTION DECITABINE  

1 MG

J1050

MEDROXYPROGESTERONE ACETATE

J1246

INJECTION DINUTUXIMAB  

0.1 MG

J1950

INJ LEUPROLIDE ACETATE PER  

3.75

MG

J1952

LEUPROLIDE INJECTABLE CAMCEVI,  

1 MG

J1954

INJECTION LA FOR DEPOT SUSPENSION  

7.5 MG

J2860

INJECTION SILTUXIMAB  

10 MG

J3240

INJ THYROTROPIN PROV 1.1 VIAL

.9 MG

J3315

INJ TRIPTORELIN PAMOATE  

3.75

MG

J3316

INJECTION TRIPTORELIN EXTENDED-RELEASE

3.75

MG

J7308

AMINOLEVULINIC ACID HCI FOR TICL ADMIN, 20%/1UNIT DOSAGE FORM  

354MG

J7502

CYCLOSPORINE, ORAL, SOL

Codes Requiring Prior Authorization Effective 1/23/2026

J7504

LYMPHOCYTE IMMUNE/ANTITHYMOCYTE GLOBULIN  

5ML EA

J7512

PDN IMMED RLSE/DELAY RLSE ORAL  

1 MG

J7520

SIROLIMUS ORAL  

1 MG

J7527

ORAL EVEROLIMUS

J8510

BUSULFAN, ORAL  

2 MG

J8520

CAPECITABINE, ORAL

150 MG

J8521

CAPECITABINE, ORAL

500 MG

J8530

CYCLOPHOSPHAMIDE ORAL  

25 MG

J8560

ETOPOSIDE ORAL  

50 MG

J8565

GEFITINIB ORAL  

250 mg

J8600

MELPHALAN ORAL  

2 MG

J8610

METHOTREXATE ORAL  

2.5 MG

J8700

TEMOZOLOMIDE ORAL  

5 MG

J8705

TOPOTECAN, ORAL  

0.25

MG

J8999

PRESCRIPTION DRUG-ORAL-CHEMOTHERAPEUTIC-NOS

J9000

INJECTION DOXORUBICIN HCL  

10 MG

J9015

ALDESLEUKIN INJECTION

J9017

INJECTION ARSENIC TRIOXIDE  

1 MG

J9019

ERWINAZE INJECTION

J9021

INJECT ASPARAGINASE RECOMBINANT (RYLAZE)  

0.1 MG

J9022

INJECTION ATEZOLIZUMAB  

10 MG

J9023

INJECTION AVELUMAB  

10 MG

J9025

INJECTION AZACITIDINE  

1 MG

J9027

INJECTION CLOFARABINE  

1 MG

J9029

IVES INSTAL NADOFARAGN FIRADENOVC-VNCG PER THR D

J9030

BCG LIVE INTRAVESICAL INSTILLATION  

1 MG

J9032

INJECTION BELINOSTAT  

10 MG

J9033

INJECTION BENDAMUSTINE HCL  

1 MG

J9034

INJ. BENDEKA  

1 MG

J9035

INJECTION BEVACIZUMAB  

10 MG

J9036

INJECTION BENDAMUSTINE HYDROCHLORIDE  

1 MG

J9037

INJECTION, BELANTAMAB MAFODOTIN-BLMF  

0.5 MG

J9039

INJECTION BLINATUMOMAB  

1 MCG

J9040

BLEOMYCIN SULFATE INJECTION

J9041

INJECTION BORTEZOMIB  

0.1 MG

J9042

BRENTUXIMAB VEDOTIN INJ

J9043

CABAZITAXEL INJECTION

J9044

INJECTION BORTEZOMIB NOS  

0.1 MG

J9045

INJECTION CARBOPLATIN  

50 MG

J9046

INJ BORTEZOMIB NOT THER EQUIV TO J9041  

0.1 MG

J9047

INJECTION, CARFILZOMIB,  

1 MG

J9048

INJ BTZ FRESENIUS KABI NOT TX EQV TO J9041  

0.1MG

J9049

INJ BORTEZOMB HOSPIRA NOT TX EQV TO J9041  

0.1 MG

J9050

INJECTION CARMUSTINE  

100 MG

J9051

INJECTION, BORTEZOMIB (MAIA), NOT THERAPEUTICALLY EQUIVALENT TO J9041  

0.1 MG

J9052

INJECTION, CARMUSTINE (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J9050  

100 MG

J9055

INJECTION CETUXIMAB  

10 MG

J9056

INJECTION BENDAMUSTINE HCL VIVIMUSTA  

1 MG

Codes Requiring Prior Authorization Effective 1/23/2026

J9057

INJECTION, COPANLISIB  

1 MG

J9058

INJECTION BENDAMUSTINE HCL APOTEX  

1 MG

J9059

INJECTION BENDAMUSTINE HCL BAXTER  

1 MG

J9060

CISPLATIN INJECTION

10 MG

J9061

INJECTION, AMIVANTAMAB-VMJW  

2 MG

J9063

INJECTION MIRVETUXIMAB SORAVTANSINE-GYNX  

1 MG

J9064

INJECTION, CABAZITAXEL (SANDOZ), NOT THERAPEUTICALLY EQUIVALENT TO J9043  

1 MG

J9065

INJ CLADRIBINE PER  

1 MG

J9070

CYCLOPHOSPHAMIDE  

100MG

J9071

INJECTION CYCLOPHOSPHAMIDE AUROMEDICS  

5 MG

J9072

INJECTION CYCLOPHOSPHAMIDE AVYXA  

5 MG

J9098

CYTARABINE LIPOSOME INJ

J9100

INJECTION CYTARABINE  

100 MG

J9118

INJECTION CALASPARGASE PEGOL-MKNL  

10 UNITS

J9119

INJECTION CEMIPLIMAB-RWLC  

1 MG

J9120

INJECTION DACTINOMYCIN  

0.5 MG

J9130

DACARBAZINE  

100 MG

J9144

INJECTION DARATUMUMAB 10 MG AND HYALURONIDASE FIHJ

J9145

INJECTION DARATUMUMAB  

10 MG

J9150

INJECTION DAUNORUBICIN  

10 MG

J9153

INJECTION LIPOSOMAL 1 MG DNR AND 2.27 MG CA

J9155

DEGARELIX INJECTION

J9171

DOCETAXEL INJECTION

J9172

INJECTION DOCETAXEL DOCIVYX  

1 MG

J9173

INJECTION DURVALUMAB  

10 MG

J9176

INJECTION ELOTUZUMAB  

1MG

J9177

INJECTION ENFORTUMAB VEDOTIN-EJFV  

0.25

MG

J9178

INJECTION, EPIRUBICIN HCI  

2 MG

J9179

ERIBULIN MESYLATE INJECTION

J9181

INJECTION ETOPOSIDE  

10 MG

J9185

FLUDARABINE PHOSPHATE INJ

J9190

INJECTION FLUOROURACIL  

500 MG

J9196

INJ GEMCITABINE HCI NOT THR EQUIV J9201  

200 MG

J9198

INJ GEMCITABINE HYDROCHLORIDE INFUGEM  

100 MG

J9200

INJECTION FLOXURIDINE  

500 MG

J9201

INJECTION GEMCITABINE HCL NOS  

200 MG

J9202

GOSERELIN ACETATE IMPLANT PER  

3.6 MG

J9203

INJ GEMTUZUMAB OZOGAMICIN  

0.1 MG

J9204

INJECTION MOGAMULIZUMAB-KPKC  

1 MG

J9205

INJ IRINOTECAN LIPOSOME  

1 MG

J9206

INJECTION IRINOTECAN  

20 MG

J9207

IXABEPILONE INJECTION

J9208

IFOSFAMIDE INJECTION

J9209

INJECTION MESNA  

200 MG

J9210

INJECTION EMAPALUMAB-LZSG  

1 MG

J9211

INJECTION IDARUBICIN HCL  

5 MG

J9214

INTERFERON ALFA-2B INJ

Codes Requiring Prior Authorization Effective 1/23/2026

J9217

LEUPROLIDE ACETATE FOR DEPOT SUSPENSION  

7.5 MG

J9218

LEUPROLIDE ACETATE PER  

1 MG

J9223

INJECTION LURBINECTEDIN  

0.1 MG

J9227

INJECTION ISATUXIMAB-IRFC  

10 MG

J9228

IPILIMUMAB INJECTION

J9229

INJECTION INOTUZUMAB OZOGAMICIN  

0.1 MG

J9230

MECHLORETHAMINE HCL INJ

J9245

INJECTION MELPHALAN HCI NOS  

50 MG

J9246

INJECTION MELPHALAN EVOMELA  

1 MG

J9247

INJECTION, MELPHALAN FLUFENAMIDE  

1 MG

J9250

METHOTREXATE SODIUM  

5 MG

J9255

INJ METHOTREXATE NOT THR EQV TO J9260  

50 MG

J9258

INJ PTX PRO-BND PA TEVA NOT EQUIV TO J9264  

1 MG

J9259

INJ PTX PRO-BND PA AMER REG NOT EQ J9264  

1 MG

J9260

INJECTION METHOTREXATE SODIUM  

50 MG

J9261

INJECTION NELARABINE  

50 MG

J9262

INJECTION, OMACETAXINE MEPESUCCINATE  

0.01

MG

J9263

INJECTION, OXALIPLATIN  

0.5 MG

J9264

INJECTION PACLITAXEL PROTEIN-BOUND PARTICLES  

1 MG

J9266

PEGASPARGASE INJECTION

J9267

PACLITAXEL INJECTION

J9268

INJECTION PENTOSTATIN  

10 MG

J9269

INJECTION TAGRAXOFUSP-ERZS  

10

MCG

J9271

INJECTION PEMBROLIZUMAB  

1 MG

J9272

INJECTION, DOSTARLIMAB-GXLY  

10 MG

J9273

INJECTION, TISOTUMAB VEDOTIN-TFTV  

1 MG

J9274

INJECTION TEBENTAFUSP-TEBN  

1 MCG

J9280

MITOMYCIN INJECTION

J9281

MITOMYCIN PYELOCALYCEAL INSTILLATION  

1 MG

J9285

INJECTION, OLARATUMAB  

10 MG

J9286

INJECTION GLOFITAMAB-GXBM  

2.5 MG

J9293

INJ MITOXANTRONE HYDROCHLORIDE PER  

5 MG

J9294

INJECTN PEMETREXED HOSPIRA NOT EQUIV J9305  

10 MG

J9295

INJECTION NECITUMUMAB  

1 MG

J9296

INJECTN PEMETREXED ACCORD NOT EQUIV J9305  

10 MG

J9297

INJ PEMETREXED SANDOZ NOT THR EQUIV J9305  

10 MG

J9298

INJECTION NIVOLUMAB AND RELATLIMAB-RMBW  

3 MG/1 MG

J9299

INJECTION NIVOLUMAB  

1 MG

J9301

OBINUTUZUMAB INJ

J9302

OFATUMUMAB INJECTION

J9303

PANITUMUMAB INJECTION

J9304

INJECTION PEMETREXED PEMFEXY  

10 MG

J9305

INJECTION PEMETREXED NOS  

10 MG

J9306

INJECTION, PERTUZUMAB  

1 MG

J9307

PRALATREXATE INJECTION

J9308

INJECTION RAMUCIRUMAB  

5 MG

J9309

INJECTION POLATUZUMAB VEDOTIN-PIIQ  

1 MG

Codes Requiring Prior Authorization Effective 1/23/2026

J9311

INJECTION RITUXIMAB 10 MG AND HYALURONIDASE

J9312

INJECTION RITUXIMAB  

10 MG

J9313

INJECTION, MOXETUMOMAB PASUDOTOX-TDFK  

0.01

MG

J9314

INJECTION PEMETREXED TEVA NOT EQUIV J9305  

10 MG

J9316

INJ PERTUZUMAB TRASTUZUMAB AND HYAL ZZXF PER  

10 MG

J9317

INJECTION SACITUZUMAB GOVITECAN HZIY  

2.5 MG

J9318

INJECTION ROMIDEPSIN NONLYOPHILIZED  

0.1 MG

J9319

INJECTION ROMIDEPSIN LYOPHILIZED  

0.1 MG

J9320

INJECTION, STREPTOZOCIN  

1 G

J9321

INJECTION EPCORITAMAB-BYSP  

0.16

MG

J9322

INJ PEMETREXED BLUEPOINT NOT EQUIV J9305  

10 MG

J9323

INJ PEMETREXED DITROMETHAMINE  

10 MG

J9324

INJECTION PEMETREXED  

10 MG

J9325

INJ TALIMOGENE LAHERPAREPVEC

J9328

TEMOZOLOMIDE INJECTION

J9330

TEMSIROLIMUS INJECTION

J9331

INJECTION SIROLIMUS PROTEIN-BOUND PARTICLES  

1 MG

J9340

INJECTION THIOTEPA  

15 MG

J9345

INJECTION, RETIFANLIMAB-DLWR  

1 MG

J9347

INJECTION TREMELIMUMAB-ACTL  

1 MG

J9348

INJECTION NAXITAMAB-GQGK  

1 MG

J9349

INJECTION TAFASITAMAB-CXIX  

2 MG

J9350

INJECTION MOSUNETUZUMAB-AXGB  

1 MG

J9351

TOPOTECAN INJECTION

J9352

INJECTION TRABECTEDIN  

0.1MG

J9353

INJECTION MARGETUXIMAB-CMKB  

5 MG

J9354

INJ, ADO-TRASTUZUMAB EMT  

1 MG

J9355

INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR  

10 MG

J9356

INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK

J9357

INJECTION, VALRUBICIN, INTRAVESICAL  

200 MG

J9358

INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI  

1 MG

J9359

INJECTION, LONCASTUXIMAB TESIRINE-LPYL  

0.075

MG

J9360

INJECTION VINBLASTINE SULFATE  

1 MG

J9370

VINCRISTINE SULFATE  

1 MG

J9371

INJ, VINCRISTINE SUL LIP  

1 MG

J9380

INJECTION TECLISTAMAB-CQYV  

0.5 MG

J9390

VINORELBINE TARTRATE INJ

J9393

INJECT FULVESTRANT NOT THR EQUIV TO J9395  

25 MG

J9394

INJ FUL FRESENIUS KABI NOT TX EQV TO J9395  

25 MG

J9395

INJECTION, FULVESTRANT  

25 MG

J9400

INJ, ZIV-AFLIBERCEPT  

1 MG

J9600

PORFIMER SODIUM INJECTION

J9999

NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUGS

Q2017

INJECTION, TENIPOSIDE  

50 MG

Q2043

SIPLEUCEL-T AUTO CD54+

Q2050

DOXORUBICIN INJ  

10 MG

Q5107

INJECTION BEVACIZUMAB-AWWB BIOSIMILAR  

10 MG

Q5112

INJECTION TRASTUZUMAB-DTTB BIOSIMILAR  

10 MG

Codes Requiring Prior Authorization Effective 1/23/2026

Q5113

INJECTION TRASTUZUMAB-PKRB BIOSIMILAR  

10 MG

Q5114

INJECTION TRASTUZUMAB-DKST BIOSIMILAR  

10 MG

Q5115

INJECTION RITUXIMAB-ABBS BIOSIMILAR  

10 MG

Q5116

INJECTION TRASTUZUMAB-QYYP BIOSIMILAR  

10 MG

Q5117

INJECTION TRASTUZUMAB-ANNS BIOSIMILAR  

10 MG

Q5118

INJECTION BEVACIZUMAB-BVZR BIOSIMILAR  

10 MG

Q5119

INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE  

10 MG

Q5123

INJECTION RITUXIMAB-ARRX BIOSIMILAR  

10 MG

Q5126

INJ BEVACIZUMAB-MALY BIOSIMILAR (ALYMSYS)  

10 MG

Q5129

INJECTION BEVACIZUMAB-ADCD BIOSIMILAR  

10 MG

S0108

MERCAPTOPURINE ORAL  

50 MG

ESA

J0881

INJECTION DARBEPOETIN ALFA NON-ESRD USE

1 MCG

J0885

INJECTION EPOETIN ALFA FOR NON-ESRD USE  

1000 U

J0888

EPOETIN BETA NON ESRD

J0896

INJECTION LUSPATERCEPT-AAMT  

0.25

MG

Q5106

INJECTION EPOETIN ALFA-EPBX BIOSIMILAR  

1000 U

IRON

J1439

INJ FERRIC CARBOXYMALTOS  

1MG

Q0138

FERUMOXYTOL, NON-ESRD

MYELOID GROWTH FACTOR

J1442

INJ FILGRASTIM EXCL BIOSIMIL

J1447

INJECTION TBO-FILGRASTIM  

1 MCG

J1449

INJECTION EFLAPEGRASTIM-XNST  

0.1 MG

J2506

INJECT PEGFILGRASTIM EXCLUDES BIOSIMILAR  

0.5 MG

J2820

INJ SARGRAMOSTIN (GM-CSF)  

50MCG

Q5101

INJECTION, ZARXIO

Q5108

INJECTION PEGFILGRASTIM-JMDB BIOSIMILAR  

0.5 MG

Q5110

INJ FILGRASTIM-AAFI BIOSIMILR  

1 MCG

Q5111

INJECTION PEGFILGRASTIM-CBQV BIOSIMILAR  

0.5 MG

Q5120

INJECTION PEGFILGRASTIM-BMEZ BIOSIMILAR  

0.5 MG

Q5122

INJECTION PEGFILGRASTIM-APGF BIOSIMILAR  

0.5 MG

Q5125

INJECTION FILGRASTIM-AYOW BIOSIMILAR  

1 MCG

Q5127

INJECTION PEG-FPGK STIMUFEND BIOSIMILAR  

0.5 MG

Q5130

INJECTION PEG-PBBK FYLNETRA BIOSIMILAR  

0.5 MG

SUPPORTIVE MEDICATION

C9047

INJECTION, CAPLACIZUMAB-YHDP  

1 MG

C9293

INJECTION, GLUCARPIDASE  

10 U

J0207

INJECTION, AMIFOSTINE  

500 MG

J1302

INJECTION SUTIMLIMAB-JOME  

10 MG

J1437

INJECTION FERRIC DERISOMALTOSE  

10 MG

J1448

INJECTION TRILACICLIB  

1 MG

J1454

INJ FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG

J1459

INJ IVIG PRIVIGEN  

500 MG

J1460

INJ GAMMA GLOBULIN IM  

1 CC

J1554

INJECTION IMMUNE GLOBULIN ASCENIV  

500 MG

J1555

INJECTION IMMUNE GLOBULIN  

100 MG

J1556

INJ, IMM GLOB BIVIGAM  

500MG

J1557

GAMMAPLEX INJECTION

Codes Requiring Prior Authorization Effective 1/23/2026

CODE

MEDICATION

DOSE

J1558

INJECTION IMMUNE GLOBULIN XEMBIFY  

100 MG

J1560

INJ GAMMA GLOBULIN IM OVER  

10 CC

J1561

GAMUNEX-C/GAMMAKED

J1566

IMMUNE GLOBULIN, POWDER

J1568

OCTAGAM INJECTION

J1569

GAMMAGARD LIQUID INJECTION

J1572

FLEBOGAMMA INJECTION

J1575

INJ IG/HYALURONIDASE  

100 MG IG

J1576

INJECTION IMMUNE GLOBULIN IV NON-LYOPH  

500 MG

J1599

IVIG NON-LYOPHILIZED, NOS

J1930

INJECTION LANREOTIDE 

1 MG

J1932

INJECTION LANREOTIDE 

1 MG

J2353

INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION 

1 MG

J2354

INJ OCTREOTIDE NON-DEPOT FORM SUBQ/IV INJ 

25

MCG

J2562

PLERIXAFOR INJECTION

J2783

INJECTION, RASBURICASE 

0.5 MG

J2796

ROMIPLOSTIM INJECTION

J3490

UNCLASSIFIED DRUGS

J3590

UNCLASSIFIED BIOLOGICS

J8499

PRESCRIPTION DRUG-ORAL-NON-CHEMOTHERAPEUTICNOS

J9216

INTERFERON GAMMA 1-B INJ