Evolent Prior Authorization Medicaid Updates 2026

Date: 01/13/26

Evolent (Formerly New Century Health) - Prior Authorization Update

Medical Oncology, Radiation Oncology, Pediatric and Dose Optimization

Effective April 1, 2026

Starting April 1, 2026, additional procedure codes will require prior authorizations through Evolent. This update also includes codes no longer covered by AHCCCS.

Applies to: Arizona Complete Health-Complete Care Plan (Medicaid) only.

Key Medicaid Reminders

Drugs from manufacturers not participating in the CMS Medicaid Drug Rebate Program (MDRP) are not are not covered
The transition to preferred biosimilars (approved at the May AHCCCS Pharmacy and Therapeutics (P&T) Committee meeting) became effective August 1, 2025
All new drugs and biosimilars are non-preferred until reviewed by AHCCCS P&T committee
Pharmacists may substitute only if the biosimilar has FDA interchangeable status
If no interchangeable designation exists, prescriber approval is required before dispensing
Providers must transition patients promptly to the AHCCCS-preferred biosimilars to avoid non-payment
Submit prior authorization requests via the Evolent Provider Portal:

Utilization Management Categories

Utilization Management Category	Description
PA Required	Prior Authorizations required for all providers. Requests should be submitted to Evolent
Not a covered benefit	Drug or HCPCS Code is not covered by AHCCCS
No PA is required	No Prior Authorization is required for any provider
PA Required for Non-PAR Providers Only	Prior Authorization required for providers who are not contracted within the health plan network. Requests should be submitted to Evolent

Questions?

Contact your Provider Engagement Account Manager. Need contact information? Email:

📧 AzCHProviderEngagement@azcompletehealth.com

CODE	MEDICATION	DOSE	Utilization Management
	ANTI-EMETICS
J1456	INJECT FOSAPREPITANT NOT THERAP EQUIV J1453	1 MG	PA Required
J1626	INJ GRANISETRON HYDROCHLORIDE	100 MCG	PA Required for Non-PAR Providers Only
J2469	INJECTION PALONOSETRON HCL	25 MCG	PA Required for Non-PAR Providers Only
Q0162	ONDAN 1 MG ORL NOT EXCEED 48 HR DOS	1 MG	PA Required for Non-PAR Providers Only
Q0166	GRANISETRON HCL ORAL CHEMO ANTI-EMETIC	1 MG	PA Required for Non-PAR Providers Only
	BONE METS
J0897	DENOSUMAB INJECTION (Prolia/Xgeva)	1 MG	PA Required
J2430	INJ PAMIDRONATE DISODIUM	30 MG	PA Required
J3590	DENOSUMAB-QBDE (Enoby/Xtrenbo)	1mg	Not a Covered Benefit
J3590	DENOSUMAB-KYQQ (Aukelso/Bosaya)	1mg	Not a Covered Benefit
J3590	DENOSUMAB-NXXP (Bildyos/Bilprevda)	1mg	Not a Covered Benefit
Q5158	DENOSUMAB-BNHT (Bomyntra/Conexxence)	1mg	Not a Covered Benefit
Q5157	DENOSUMAB-BMWO (Stobocio/Osenvelt)	1mg	Not a Covered Benefit
Q5159	DENOSUMAB-DSSB (Ospomyv/Xbyrk)	1mg	Not a Covered Benefit
Q5136	DENOSUMAB-BBDZ (Jubbonti/Wyost)	1mg	Not a Covered Benefit
J3489	ZOLEDRONIC ACID	1MG	PA Required
	CANCER TREATMENT
C9155	INJECTION EPCORITAMAB-BYSP	0.16 MG	Not a Covered Benefit
C9163	INJECTION TALQUETAMAB-TGVS	0.25 MG	Not a Covered Benefit
C9165	INJECTION ELRANATAMAB-BCMM	1 MG	Not a Covered Benefit
J0202	INJECTION ALEMTUZUMAB	1 MG	PA Required
J0594	INJECTION BUSULFAN	1 MG	PA Required
J0640	INJ LEUCOVORIN CALCIUM PER	50 MG	PA Required
J0641	INJECTION LEVOLEUCOVORIN NOS	0.5 MG	PA Required
J0642	Injection, levoleucovorin (Khapzory)	0.5 mg	PA Required
J0791	INJECTION CRIZANLIZUMAB-TMCA	5 MG	PA Required
J0893	INJECTION DECITABINE NOT THR EQUIV TO J0894	1 MG	PA Required
J0894	INJECTION DECITABINE	1 MG	PA Required
J1050	MEDROXYPROGESTERONE ACETATE	1 MG	PA Required for Non-PAR Providers Only
J1246	INJECTION DINUTUXIMAB	0.1 MG	Not a Covered Benefit
J1950	INJ LEUPROLIDE ACETATE PER	3.75 MG	PA Required
J1952	LEUPROLIDE INJECTABLE CAMCEVI,	1 MG	PA Required
J1954	INJECTION LA FOR DEPOT SUSPENSION	7.5 MG	PA Required
J2860	INJECTION SILTUXIMAB	10 MG	PA Required
J3240	INJ THYROTROPIN PROV 1.1 VIAL	.9 MG	PA Required

CODE	MEDICATION	DOSE	Utilization Management
J3315	INJ TRIPTORELIN PAMOATE	3.75 MG	PA Required
J3316	INJECTION TRIPTORELIN EXTENDED-RELEASE	3.75 MG	PA Required
J7308	AMINOLEVULINIC ACID HCI FOR TICL ADMIN, 20%/1UNIT DOSAGE FORM	354MG	PA Required for Non-PAR Providers Only
J7502	CYCLOSPORINE, ORAL, SOL	100 MG	PA Required
J7504	LYMPHOCYTE IMMUNE/ANTITHYMOCYTE GLOBULIN	5ML EA	PA Required
J7512	PDN IMMED RLSE/DELAY RLSE ORAL	1 MG	PA Required for Non-PAR Providers Only
J7520	SIROLIMUS ORAL	1 MG	PA Required for Non-PAR Providers Only
J7527	ORAL EVEROLIMUS	0.25 MG	PA Required
J8510	BUSULFAN, ORAL	2 MG	PA Required
J8522	CAPECITABINE, ORAL	50 MG	PA Required
J8530	CYCLOPHOSPHAMIDE ORAL	25 MG	PA Required
J8560	ETOPOSIDE ORAL	50 MG	PA Required
J8600	MELPHALAN ORAL	2 MG	PA Required
J8610	METHOTREXATE ORAL	2.5 MG	PA Required
J8612	METHOTREXATE ORAL (xatmep)	2.5 MG	PA Required for Non-PAR Providers Only
	CANCER TREATMENT
J8700	TEMOZOLOMIDE ORAL	5 MG	PA Required
J8705	Topotecan, oral	0.25 mg	PA Required
J8999	PRESCRIPTION DRUG-ORAL-CHEMOTHERAPEUTIC-NOS	N/A	Not a Covered Benefit
J9000	INJECTION DOXORUBICIN HCL	10 MG	PA Required
J9001	INJECTION DOXORUBICIN HCL, all lipid formulations	10 MG	Not a Covered Benefit
Q2050	INJECTION DOXORUBICIN HCL, LIPOSOMAL, not otherwise specified	10 MG	PA Required
J9002	INJECTION DOXORUBICIN HCL, LIPOSOMAL, doxil	10 MG	Not a Covered Benefit
Q2049	INJECTION DOXORUBICIN HCL, LIPOSOMAL, imported Lipodox	10 MG	PA Required
J9015	ALDESLEUKIN INJECTION	PER VIAL	Not a Covered Benefit
J9017	INJECTION ARSENIC TRIOXIDE	1 MG	PA Required
J9019	ERWINAZE INJECTION	1000 U	PA Required
J9021	INJECT ASPARAGINASE RECOMBINANT (RYLAZE)	0.1 MG	PA Required
J9022	INJECTION ATEZOLIZUMAB	10 MG	PA Required
J9023	INJECTION AVELUMAB	10 MG	PA Required
J9025	INJECTION AZACITIDINE	1 MG	PA Required
J9027	INJECTION CLOFARABINE	1 MG	PA Required
J9029	IVES INSTAL NADOFARAGN FIRADENOVC-VNCG PER THR D	PER VIAL	PA Required
J9030	BCG LIVE INTRAVESICAL INSTILLATION	1 MG	PA Required

CODE		MEDICATION	DOSE	Utilization Management
	J9032	INJECTION BELINOSTAT	10 MG	PA Required
	J9033	INJECTION BENDAMUSTINE HCL (Used for Treanda and its generic equivalents	1 MG	PA Required
	J9034	INJ. INJECTION BENDAMUSTINE HCL (Bendeka)	1 MG	PA Required
	J9035	INJECTION BEVACIZUMAB	10 MG	PA Required for Non-PAR Providers Only
	J9036	INJECTION BENDAMUSTINE HYDROCHLORIDE (Belrapzo)	1 MG	Not a Covered Benefit
	J9037	Injection, belantamab mafodotin-blmf	0.5 MG	Not a Covered Benefit
	J9039	INJECTION BLINATUMOMAB	1 MCG	PA Required
	J9040	BLEOMYCIN SULFATE INJECTION	15 units	PA Required
	J9041	INJECTION BORTEZOMIB	0.1 MG	PA Required
	J9042	BRENTUXIMAB VEDOTIN INJ	1 MG	PA Required
	J9043	CABAZITAXEL INJECTION (Jevtana)	1 MG	PA Required
	J9045	INJECTION CARBOPLATIN	50 MG	PA Required
	J9046	INJ BORTEZOMIB NOT THER EQUIV TO J9041	0.1 MG	PA Required
	J9047	INJECTION, CARFILZOMIB	1 MG	PA Required
	J9048	INJ BTZ FRESENIUS KABI NOT TX EQV TO J9041	0.1MG	PA Required
	J9049	INJ BORTEZOMB HOSPIRA NOT TX EQV TO J9041	0.1 MG	PA Required
	J9050	INJECTION CARMUSTINE	100 MG	PA Required
	J9051	Injection, bortezomib (MAIA), not therapeutically equivalent to J9041	0.1 mg	PA Required
	J9052	Injection, carmustine (Accord), not therapeutically equivalent to J9050	100 mg	PA Required
	J9055	INJECTION CETUXIMAB	10 MG	PA Required
	J9056	INJECTION BENDAMUSTINE HCL (Vivimusta)	1 MG	PA Required
	J9057	Injection, copanlisib	1 mg	PA Required
	J9058	INJECTION BENDAMUSTINE HCL (Apotex)	1 MG	Not a Covered Benefit
	J9059	INJECTION BENDAMUSTINE HCL (Baxter)	1 MG	Not a Covered Benefit
	J9060	CISPLATIN INJECTION	10 MG	PA Required
	J9061	INJECTION, AMIVANTAMAB-VMJW	2 MG	PA Required
	J9063	INJECTION MIRVETUXIMAB SORAVTANSINE-GYNX	1 MG	PA Required
	J9064	Injection, cabazitaxel (Sandoz), not therapeutically equivalent to J9043	1 mg	Not a Covered Benefit
	J9065	INJ CLADRIBINE PER	1 MG	PA Required
	J9070	CYCLOPHOSPHAMIDE	100MG	Not a Covered Benefit
	J9071	INJECTION CYCLOPHOSPHAMIDE (Auromedics)	5 MG	PA Required for Non-PAR Providers Only
	J9072	INJECTION CYCLOPHOSPHAMIDE (Frindovyx)	5 MG	PA Required
	J9073	INJECTION CYCLOPHOSPHAMIDE (Dr Reddy's)	5 MG	PA Required
	J9074	INJECTION CYCLOPHOSPHAMIDE (Sandoz)	5 MG	PA Required
	J9075	INJECTION CYCLOPHOSPHAMIDE (not otherwise specified)	5 MG	PA Required
	J9076	INJECTION CYCLOPHOSPHAMIDE (Baxter)	5 MG	Not a Covered Benefit
CODE		MEDICATION	DOSE	Utilization Management
	J9098	CYTARABINE LIPOSOME INJ	10 MG	Not a Covered Benefit
	J9100	INJECTION CYTARABINE	100 MG	PA Required
	J9118	INJECTION CALASPARGASE PEGOL-MKNL	10 UNITS	PA Required
	J9119	INJECTION CEMIPLIMAB-RWLC	1 MG	PA Required
	J9120	INJECTION DACTINOMYCIN	0.5 MG	PA Required
	J9130	DACARBAZINE	100 MG	PA Required
	J9144	INJECTION DARATUMUMAB 10 MG AND HYALURONIDASE FIHJ	10 MG	PA Required
	J9145	INJECTION DARATUMUMAB	10 MG	PA Required
	J9150	INJECTION DAUNORUBICIN	10 MG	PA Required
	J9153	INJECTION LIPOSOMAL 1 MG DNR AND 2.27 MG CA	1 MG/2.27 MG	PA Required
	J9155	DEGARELIX INJECTION	1 MG	PA Required
	J9171	DOCETAXEL INJECTION	1 MG	PA Required
	J9172	INJECTION DOCETAXEL (Docivyx)	1 MG	Not a Covered Benefit
	J9173	INJECTION DURVALUMAB	10 MG	PA Required
	J9174	INJECTION DOCETAXEL (Beizray)	10 MG	PA Required
	J9176	INJECTION ELOTUZUMAB	1MG	PA Required
	J9177	INJECTION ENFORTUMAB VEDOTIN-EJFV	0.25 MG	PA Required
	J9178	INJECTION, EPIRUBICIN HCI	2 MG	PA Required
	J9179	ERIBULIN MESYLATE INJECTION	0.1 MG	PA Required
	J9181	INJECTION ETOPOSIDE	10 MG	PA Required
	J9185	FLUDARABINE PHOSPHATE INJ	50 MG	PA Required
	J9190	INJECTION FLUOROURACIL	500 MG	PA Required
	J9196	INJ GEMCITABINE HCI NOT THR EQUIV J9201	200 MG	PA Required
	J9198	INJ GEMCITABINE HYDROCHLORIDE INFUGEM	100 MG	PA Required
	J9200	INJECTION FLOXURIDINE	500 MG	PA Required
	J9201	INJECTION GEMCITABINE HCL NOS	200 MG	PA Required
	J9202	GOSERELIN ACETATE IMPLANT PER	3.6 MG	Not a Covered Benefit
	J9203	INJ GEMTUZUMAB OZOGAMICIN	0.1 MG	PA Required
	J9204	INJECTION MOGAMULIZUMAB-KPKC	1 MG	PA Required
	J9205	INJ IRINOTECAN LIPOSOME	1 MG	PA Required
	J9206	INJECTION IRINOTECAN	20 MG	PA Required
	J9207	IXABEPILONE INJECTION	1 MG	PA Required
	J9208	IFOSFAMIDE INJECTION	1 GM	PA Required
	J9209	INJECTION MESNA	200 MG	PA Required
	J9210	INJECTION EMAPALUMAB-LZSG	1 MG	PA Required
	J9211	INJECTION IDARUBICIN HCL	5 MG	PA Required
	J9214	INTERFERON ALFA-2B INJ	1 million Units	PA Required
	J9217	LEUPROLIDE ACETATE FOR DEPOT SUSPENSION	7.5 MG	PA Required
CODE		MEDICATION	DOSE	Utilization Management
	J9218	LEUPROLIDE ACETATE PER	1 MG	PA Required
	J9223	INJECTION LURBINECTEDIN	0.1 MG	PA Required
	J9227	INJECTION ISATUXIMAB-IRFC	10 MG	PA Required
	J9228	IPILIMUMAB INJECTION	1 MG	PA Required
	J9229	INJECTION INOTUZUMAB OZOGAMICIN	0.1 MG	PA Required
	J9230	MECHLORETHAMINE HCL INJ	10 MG	Not a Covered Benefit
	J9245	INJECTION MELPHALAN HCI NOS	50 MG	PA Required
	J9246	INJECTION MELPHALAN EVOMELA	1 MG	PA Required
	J9247	Injection, melphalan flufenamide	1 mg	Not a Covered Benefit
	J9255	INJ METHOTREXATE NOT THR EQV TO J9260	50 MG	Not a Covered Benefit
	J9260	INJECTION METHOTREXATE SODIUM	50 MG	PA Required
	J9261	INJECTION NELARABINE	50 MG	PA Required
	J9262	Injection, omacetaxine mepesuccinate	0.01 mg	PA Required
	J9263	INJECTION, OXALIPLATIN	0.5 MG	PA Required
	J9264	INJECTION PACLITAXEL PROTEIN-BOUND PARTICLES	1 MG	PA Required
	J9266	PEGASPARGASE INJECTION	PER VIAL	PA Required
	J9267	PACLITAXEL INJECTION	1 MG	PA Required
	J9268	INJECTION PENTOSTATIN	10 MG	PA Required
	J9269	INJECTION TAGRAXOFUSP-ERZS	10 MCG	PA Required
	J9271	INJECTION PEMBROLIZUMAB	1 MG	PA Required
	J9272	INJECTION, DOSTARLIMAB-GXLY	10 MG	PA Required
	J9273	INJECTION, TISOTUMAB VEDOTIN-TFTV	1 MG	PA Required
	J9274	INJECTION TEBENTAFUSP-TEBN	1 MCG	PA Required
	J9280	MITOMYCIN INJECTION	5 MG	PA Required
	J9281	MITOMYCIN PYELOCALYCEAL INSTILLATION	1 MG	PA Required
	J9285	Injection, olaratumab	10 mg	Not a Covered Benefit
	J9286	INJECTION GLOFITAMAB-GXBM	2.5 MG	PA Required
	J9293	INJ MITOXANTRONE HYDROCHLORIDE PER	5 MG	PA Required
	J9294	INJECTN PEMETREXED HOSPIRA NOT EQUIV J9305	10 MG	PA Required
	J9295	INJECTION NECITUMUMAB	1 MG	PA Required
	J9296	INJECTN PEMETREXED ACCORD NOT EQUIV J9305	10 MG	PA Required
	J9297	INJ PEMETREXED SANDOZ NOT THR EQUIV J9305	10 MG	PA Required
	J9298	INJECTION NIVOLUMAB AND RELATLIMAB-RMBW	3 MG/1 MG	PA Required
	J9299	INJECTION NIVOLUMAB	1 MG	PA Required
	J9301	OBINUTUZUMAB INJ	10 MG	PA Required
	J9302	OFATUMUMAB INJECTION	10 MG	PA Required
	J9303	PANITUMUMAB INJECTION	10 MG	PA Required
	J9304	INJECTION PEMETREXED PEMFEXY	10 MG	Not a Covered Benefit
	J9305	INJECTION PEMETREXED NOS	10 MG	PA Required
CODE		MEDICATION	DOSE	Utilization Management
	J9306	INJECTION, PERTUZUMAB	1 MG	PA Required
	J9307	PRALATREXATE INJECTION	1 MG	PA Required
	J9308	INJECTION RAMUCIRUMAB	5 MG	PA Required
	J9309	INJECTION POLATUZUMAB VEDOTIN-PIIQ	1 MG	PA Required
	J9311	INJECTION RITUXIMAB 10 MG AND HYALURONIDASE	10 MG	PA Required
	J9312	INJECTION RITUXIMAB	10 MG	PA Required
	J9313	Injection, moxetumomab pasudotox-tdfk	0.01 mg	PA Required
	J9314	INJECTION PEMETREXED TEVA NOT EQUIV J9305	10 MG	PA Required
	J9316	INJ PERTUZUMAB TRASTUZUMAB AND HYAL ZZXF PER	10 MG	PA Required
	J9317	INJECTION SACITUZUMAB GOVITECAN HZIY	2.5 MG	PA Required
	J9318	INJECTION ROMIDEPSIN NONLYOPHILIZED	0.1 MG	PA Required
	J9319	INJECTION ROMIDEPSIN LYOPHILIZED	0.1 MG	PA Required
	J9320	Injection, streptozocin	1 g	PA Required
	J9321	INJECTION EPCORITAMAB-BYSP	0.16 MG	PA Required
	J9322	INJ PEMETREXED BLUEPOINT NOT EQUIV J9305	10 MG	PA Required
	J9323	INJ PEMETREXED DITROMETHAMINE	10 MG	PA Required
	J9324	INJECTION PEMETREXED	10 MG	PA Required
	J9325	INJ TALIMOGENE LAHERPAREPVEC	1 million Units	PA Required
	J9328	TEMOZOLOMIDE INJECTION	1 MG	PA Required
	J9330	TEMSIROLIMUS INJECTION	1 MG	PA Required
	J9331	INJECTION SIROLIMUS PROTEIN-BOUND PARTICLES	1 MG	PA Required
	J9340	INJECTION THIOTEPA	15 MG	PA Required
	J9345	Injection, retifanlimab-dlwr	1 mg	PA Required
	J9347	INJECTION TREMELIMUMAB-ACTL	1 MG	PA Required
	J9348	INJECTION NAXITAMAB-GQGK	1 MG	PA Required
	J9349	INJECTION TAFASITAMAB-CXIX	2 MG	PA Required
	J9350	INJECTION MOSUNETUZUMAB-AXGB	1 MG	PA Required
	J9351	TOPOTECAN INJECTION	1 MG	PA Required
	J9352	INJECTION TRABECTEDIN	0.1MG	PA Required
	J9353	INJECTION MARGETUXIMAB-CMKB	5 MG	Not a Covered Benefit
	J9354	INJ, ADO-TRASTUZUMAB EMT	1 MG	PA Required
	J9355	INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR	10 MG	PA Required
	J9356	INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK	10 MG	PA Required
	J9357	Injection, valrubicin, intravesical	200 mg	PA Required
	J9358	INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI	1 MG	PA Required
	J9359	INJECTION, LONCASTUXIMAB TESIRINE-LPYL	0.075 MG	PA Required
	J9360	INJECTION VINBLASTINE SULFATE	1 MG	PA Required
CODE		MEDICATION	DOSE	Utilization Management
	J9370	VINCRISTINE SULFATE	1 MG	PA Required
	J9380	INJECTOIN TECLISTAMAB-CQYV	0.5 MG	PA Required
	J9390	VINORELBINE TARTRATE INJ	10 MG	PA Required
	J9393	INJECT FULVESTRANT NOT THR EQUIV TO J9395	25 MG	PA Required
	J9394	INJ FUL FRESENIUS KABI NOT TX EQV TO J9395	25 MG	PA Required
	J9395	INJECTION, FULVESTRANT	25 MG	PA Required
	J9400	INJ, ZIV-AFLIBERCEPT	1 MG	PA Required
	J9600	PORFIMER SODIUM INJECTION	75 MG	PA Required
	J9999	NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUGS	N/A	PA Required
	Q2017	Injection, teniposide	50 mg	PA Required
	Q2043	SIPLEUCEL-T AUTO CD54+	N/A	PA Required
	Q2050	DOXORUBICIN INJ	10 MG	PA Required
	Q5107	INJECTION BEVACIZUMAB-AWWB BIOSIMILAR	10 MG	PA Required
	Q5112	INJECTION TRASTUZUMAB-DTTB BIOSIMILAR	10 MG	Not a Covered Benefit
	Q5113	INJECTION TRASTUZUMAB-PKRB BIOSIMILAR	10 MG	Not a Covered Benefit
	Q5114	INJECTION TRASTUZUMAB-DKST BIOSIMILAR	10 MG	PA Required
	Q5115	INJECTION RITUXIMAB-ABBS BIOSIMILAR	10 MG	Not a Covered Benefit
	Q5116	INJECTION TRASTUZUMAB-QYYP BIOSIMILAR	10 MG	Not a Covered Benefit
	Q5117	INJECTION TRASTUZUMAB-ANNS BIOSIMILAR	10 MG	Not a Covered Benefit
	Q5118	INJECTION BEVACIZUMAB-BVZR BIOSIMILAR	10 MG	PA Required
	Q5119	INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE	10 MG	PA Required
	Q5123	INJECTION RITUXIMAB-ARRX BIOSIMILAR	10 MG	PA Required
	Q5126	INJ BEVACIZUMAB-MALY BIOSIMILAR (ALYMSYS)	10 MG	Not a Covered Benefit
	Q5129	INJECTION BEVACIZUMAB-ADCD BIOSIMILAR	10 MG	Not a Covered Benefit
	S0108	MERCAPTOPURINE ORAL	50 MG	Not a Covered Benefit
		ESA
	J0881	INJECTION DARBEPOETIN ALFA NON-ESRD USE	1 MCG	PA Required
	J0885	INJECTION EPOETIN ALFA FOR NON-ESRD USE	1000 U	PA Required
	J0888	EPOETIN BETA NON ESRD	1 MCG	Not a Covered Benefit
	J0896	INJECTION LUSPATERCEPT-AAMT	0.25 MG	PA Required
	Q5106	INJECTION EPOETIN ALFA-EPBX BIOSIMILAR	1000 U	PA Required
		IRON
	J1439	INJ FERRIC CARBOXYMALTOS	1MG	PA Required
	J1750	INJ IRON DEXTRAN	50 MG	PA Required for Non-PAR Providers Only
	J1756	INJECTION IRON SUCROSE	1 MG	PA Required for Non-PAR Providers Only
	J2916	INJ SODIM FERRIC GLUCONATE	12.5 MG	PA Required for Non-PAR Providers Only
	Q0138	INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY	N/A	PA Required
CODE		MEDICATION	DOSE	Utilization Management
		MYELOID GROWTH FACTOR
	J1442	INJ FILGRASTIM EXCL BIOSIMIL	1 MCG	Not a Covered Benefit
	J1447	INJECTION TBO-FILGRASTIM	1 MCG	Not a Covered Benefit
	J1449	INJECTION EFLAPEGRASTIM-XNST	0.1 MG	PA Required
	J2506	INJECT PEGFILGRASTIM EXCLUDES BIOSIMILAR	0.5 MG	PA Required
	J2820	INJ SARGRAMOSTIN (GM-CSF)	50MCG	PA Required
	Q5101	INJECTION, ZARXIO	1 MCG	Not a Covered Benefit
	Q5108	INJECTION PEGFILGRASTIM-JMDB BIOSIMILAR	0.5 MG	PA Required
	Q5110	INJ FILGRASTIM-AAFI BIOSIMILR	1 MCG	PA Required
	Q5111	INJECTION PEGFILGRASTIM-CBQV BIOSIMILAR	0.5 MG	Not a Covered Benefit
	Q5120	INJECTION PEGFILGRASTIM-BMEZ BIOSIMILAR	0.5 MG	Not a Covered Benefit
	Q5122	INJECTION PEGFILGRASTIM-APGF BIOSIMILAR	0.5 MG	Not a Covered Benefit
	Q5125	INJECTION FILGRASTIM-AYOW BIOSIMILAR	1 MCG	PA Required
	Q5127	INJECTION PEG-FPGK STIMUFEND BIOSIMILAR	0.5 MG	Not a Covered Benefit
	Q5130	INJECTION PEG-PBBK FYLNETRA BIOSIMILAR	0.5 MG	Not a Covered Benefit
		SUPPORTIVE MEDICATION
	C9047	INJECTION, CAPLACIZUMAB-YHDP	1 MG	PA Required
	J2470	INJECTION, PANTOPRAZOLE SODIUM	40 MG	PA Required
	J2472	INJECTION, PANTOPRAZOLE SODIUM IN SODIUM CHLORIDE (Baxter)	40 MG	PA Required for Non-PAR Providers Only
	C9113	INJECTION, PANTOPRAZOLE SODIUM, PER VIAL	40 MG	Not a Covered Benefit
	C9293	Injection, glucarpidase	10 u	Only covered at OP Hospital
	J0171	ADRENALIN EPINEPHRINE INJECT	0.1 MG	PA Required for Non-PAR Providers Only
	J0185	INJECTION APREPITANT	1 MG	PA Required
	J0207	Injection, amifostine	500 mg	PA Required for Non-PAR Providers Only
	J0208	INJECTION SODIUM THIOSULFATE	100 MG	PA Required
	J0612	INJECTION CALCIUM GLUCONATE NOS	10 MG	PA Required for Non-PAR Providers Only
	J0613	INJECTION CAGLU NOT THERAP EQUIV TO J0612	10 MG	PA Required for Non-PAR Providers Only
	J0630	INJ CALCITONIN SALMON TO	400 U	PA Required for Non-PAR Providers Only
	J0780	INJ PROCHLORPERAZINE TO	10 MG	PA Required for Non-PAR Providers Only
	J0895	INJ DEFEROXAMINE MESYLATE	500 MG PER 5 CC	PA Required for Non-PAR Providers Only
		SUPPORTIVE MEDICATION
	J1100	INJ DEXMETHOSON SODIM PHOSHATE	1 MG	PA Required for Non-PAR Providers Only
	J1190	INJ DEXRAZOXANE HYDROCHLORIDE PER	250 MG	PA Required
	J1200	INJ DIPHENHYDRAMINE HCL TO	50 MG	PA Required for Non-PAR Providers Only
	J1260	Injection, dolasetron mesylate	10 mg	Not a Covered Benefit
CODE		MEDICATION	DOSE	Utilization Management
	J1302	INJECTION SUTIMLIMAB-JOME	10 MG	PA Required
	J1410	INJ ESTROGEN CONJUGATED PER 25 MG	25 MG	PA Required for Non-PAR Providers Only
	J1437	INJECTION FERRIC DERISOMALTOSE	10 MG	PA Required
	J1448	INJECTION TRILACICLIB	1 MG	PA Required
	J1453	FOSAPREPITANT INJECTION		PA Required
	J1454	INJ FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG	235/0.25 MG	PA Required
	J1459	INJ IVIG PRIVIGEN	500 MG	PA Required
	J1460	INJ GAMMA GLOBULIN IM	1 CC	PA Required
	J1554	INJECTION IMMUNE GLOBULIN ASCENIV	500 MG	PA Required
	J1555	INJECTION IMMUNE GLOBULIN	100 MG	PA Required
	J1556	INJ, IMM GLOB BIVIGAM	500MG	PA Required
	J1557	GAMMAPLEX INJECTION	500 MG	PA Required
	J1558	INJECTION IMMUNE GLOBULIN XEMBIFY	100 MG	PA Required
	J1560	INJ GAMMA GLOBULIN IM OVER	10 CC	PA Required
	J1561	GAMUNEX-C/GAMMAKED	500 MG	PA Required
	J1566	IMMUNE GLOBULIN, POWDER	500 MG	PA Required
	J1568	OCTAGAM INJECTION	500 MG	PA Required
	J1569	GAMMAGARD LIQUID INJECTION	500 MG	PA Required
	J1572	FLEBOGAMMA INJECTION	500 MG	PA Required
	J1575	INJ IG/HYALURONIDASE	100 MG IG	PA Required
	J1576	INJECTION IMMUNE GLOBULIN IV NON-LYOPH	500 MG	PA Required
	J1599	IVIG NON-LYOPHILIZED, NOS	500 MG	PA Required
	J1627	INJ GRANISETRON EXT-RLSE	0.1 MG	PA Required
	J1630	INJ HALOPERIDOL TO 5 MG	5 MG	PA Required for Non-PAR Providers Only
	J1643	INJECT HEPARIN SOD NOT THERAP EQUIV J1644	1000 U	PA Required for Non-PAR Providers Only
	J1720	INJ HYDROCORTISONE SODIUM SUCCINATE TO	100 MG	PA Required for Non-PAR Providers Only
	J1790	INJ DROPERIDOL TO 5 MG	5 MG	PA Required for Non-PAR Providers Only
	J1930	INJECTION LANREOTIDE	1 MG	PA Required
	J1932	INJECTION LANREOTIDE	1 MG	PA Required
	J2212	METHYLNALTREXONE INJECTION	PER VIAL	PA Required
	J2353	INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION	1 MG	PA Required
	J2354	INJ OCTREOTIDE NON-DEPOT FORM SUBQ/IV INJ	25 MCG	PA Required
	J2405	INJ ONDANSETRON HCL PER 1 MG	1 MG	PA Required for Non-PAR Providers Only
	J2425	INJECTION PALIFERMIN	50 MCG	PA Required
	J2550	INJ PROMETHAZINE HCL TO 50 MG	50 MG	PA Required for Non-PAR Providers Only
CODE		MEDICATION	DOSE	Utilization Management
	J2562	PLERIXAFOR INJECTION	1 MG	PA Required
	J2765	INJ METOCLOPRAMIDE HCL TO 10 MG	10 MG	PA Required for Non-PAR Providers Only
	J2780	INJECTION, RANITIDINE HYDROCHLORIDE	25 MG	PA Required for Non-PAR Providers Only
		SUPPORTIVE MEDICATION
	J2783	INJECTION, RASBURICASE	0.5 MG	PA Required
	J2790	RHO D IMMUNE GLOBULIN INJ	300 MG	PA Required for Non-PAR Providers Only
	J2792	INJ RHO D IMMUNE GLOBULIN IV HUMAN	100 IU	PA Required
	J2802	ROMIPLOSTIM INJECTION	1 MCG	PA Required
	J2919	INJ METHYLPREDNISOLONE SODIUM SUCCINATE	5 MG	PA Required for Non-PAR Providers Only
	J3410	INJ HYDROXYZINE HCL TO 25 MG	25 MG	PA Required for Non-PAR Providers Only
	J3411	INJECTION, THIAMINE HCI	100 MG	PA Required for Non-PAR Providers Only
	J3420	INJ VITAMIN B-12 CYANOCOBALAMIN TO 1000 MCG	1000 MCG	PA Required for Non-PAR Providers Only
	J3430	INJ PHYTONADIONE (VIT K) PER 1 MG	1 MG	PA Required for Non-PAR Providers Only
	J3471	INJECTION HYALURONIDASE OVINE PRESERVATIVE FREE /1 USP UNIT UP TO 999	N/A	PA Required for Non-PAR Providers Only
	J3475	INJECTION, MAGNESIUM SULFATE, PER 500 MG	500 MG	PA Required for Non-PAR Providers Only
	J3480	INJECTION, POTASSUIM CHLORIDE, PER 2 MEQ	2 MEQ	PA Required for Non-PAR Providers Only
	J3490	UNCLASSIFIED DRUGS	N/A	PA Required for Non-PAR Providers Only
	J3590	UNCLASSIFIED BIOLOGICS	N/A	PA Required for Non-PAR Providers Only
	J7510	PREDNISOLONE ORAL PER 5 MG	5 MG	PA Required for Non-PAR Providers Only
	J7515	CYCLOSPORINE, ORAL 25 MG	25 MG	PA Required
	J8499	PRESCRIPTION DRUG-ORAL-NON-CHEMOTHERAPEUTIC-NOS	N/A	PA Required
	J8501	APREPITANT ORAL	5 MG	PA Required
	J8540	DEXAMETHASONE ORAL	0.25 MG	PA Required for Non-PAR Providers Only
	J8655	NETUPITANT 300 MG AND PALONOSETRON 0.5 MG ORAL	N/A	PA Required
	J8670	ROLAPITANT ORAL	1MG	Not a Covered Benefit
	J9216	INTERFERON GAMMA 1-B INJ	N/A	PA Required
	P9045	INFUSION, ALBUMIN (HUMAN), 5%, 250 ML	N/A	No PA is required.
	P9046	INFUSION, ALBUMIN (HUMAN), 25%, 20 ML	N/A	No PA is required.



CODE		MEDICATION	DOSE	Utilization Management
	P9047	INFUSION, ALBUMIN (HUMAN), 25%, 50 ML	N/A	No PA is required.
	Q0163	DIPHENHYDRAMINE HCL ORAL CHEMO ANTI-EMETIC	50 MG	PA Required for Non-PAR Providers Only
	Q0164	PROCHLORPERAZINE MALEATE ORAL ANTI-EMETIC	5 MG	PA Required for Non-PAR Providers Only
	Q0167	DRONABINOL ORAL APPRVD CHEMO ANTI-EMETIC	2.5 MG	PA Required for Non-PAR Providers Only
	Q0169	PROMETHAZINE HCL ORAL CHEMO ANTI-EMETIC	12.5 MG	PA Required for Non-PAR Providers Only
	Q0177	HYDROXYZINE PAMOATE 25 MG ORAL CHEMO ANTI-EMETIC	25 MG	PA Required for Non-PAR Providers Only
	Q0180	Dolasetron mesylate, 100 mg, oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment	N/A	PA Required for Non-PAR Providers Only
	S0176	HYDROXYUREA, ORAL	500MG	Not a Covered Benefit