Provider Alerts

Effective September 8, 2025, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

1. Code J2267 – INJECTION, MIRIKIZUMAB-MRKZ, (OMVOH) 1 MG, Code J1628 – INJECTION, GUSELKUMAB (TREMFYA) 1 MG: PA required. Must be prescribed by a gastroenterologist. Reserved for treatment of Ulcerative Colitis and Crohn’s disease. Reserved for treatment failure to tumor necrosis factor (TNF) inhibitors AND have tried and failed Stelara.
2. Code Q9999 – INJECTION, USTEKINUMAB-AAUZ (OTULFI), BIOSIMILAR PER 1.0 MG: PA required. Must be prescribed by a gastroenterologist. Reserved for treatment of Crohn’s Disease and Ulcerative Colitis. Reserved for treatment failure to tumor necrosis factor (TNF) inhibitors.
3. Code 90683 – INTRAMUSCULAR, RESPIRATORY SYNCYTIAL VIRUS VACCINE (MRESVIA®): No PA required.
4. Code Q5147 – INJECTION, AFLIBERCEPT-AYYH (PAVBLU) 1 MG: PA required. Must meet ALL of the following:

• Eye condition appropriate for treatment, including:

1. Diabetic macular edema, with or without diabetic retinopathy
2. Macular edema following central or branch vein occlusion
3. Neovascular (wet or exudative) age-related macular degeneration
4. Indication approved by FDA or society guidelines

• No concurrent ocular or periocular infection;
• Age 18 years or older;
• AND must have failed or had clinically significant adverse effects to bevacizumab unless patient’s baseline visual acuity is 20/50 or worse.
• Limited to standard dosing of one 2 mg dose per eye every 4 weeks.

5. Code Q5133 – INJECTION, TOCILIZUMAB-BAVI (TOFIDENCE), BIOSIMILAR, 1 MG; CODE Q5135- INJECTION, TOCILIZUMAB-AAZG (TYENNE), BIOSIMILAR, 1 MG: PA required. Must be prescribed by a rheumatologist. Treatment failure to Adalimumab, Etanercept, Infliximab, Golimumab, Sarilumab, or Rituximab biosimilars.
6. Code J0717 – INJECTION, CERTOLIZUMAB PEGOL, (CIMZIA) 1 MG:

For treatment of Axial Spondyloarthritis: PA required. Must be prescribed by a rheumatologist. Must meet one of the following:

• Treatment failure to Adalimumab, Etanercept, Infliximab, OR
• Women that are currently pregnant or breastfeeding,
• Diagnosed with non-radiographic axial spondyloarthritis (nr-axSpA) and tried and failed at least 2 different NSAIDs over 1 month.

7. Code J3489 INJECTION, ZOLEDRONIC ACID, 1 MG: No PA needed for office-based or in-network facilities. Limited to 5 units per 365 days.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org