Provider Alerts

Effective August 31, 2026, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit. 

1. Code J1745 – INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, (REMICADE) 10 MG, Code Q5104 – INJECTION, INFLIXIMAB-ABDA, BIOSIMILAR, (RENFLEXIS) 10 MG, Code Q5103 – INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA) 10 MG, Code Q5121 – INJECTION, INFLIXIMAB-AXXQ, BIOSIMILAR, (AVSOLA) 10 MG: Prior Authorization (PA) required. Must be prescribed by gastroenterologist.

a) For Crohn’s disease or clinically defined moderate to severely active ulcerative colitis OR
b) For mild to moderately active ulcerative colitis: Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathioprine, Mercaptopurine, Mesalamine, and Sulfasalazine) OR intolerance to corticosteroids.
c) For non-preferred products Remicade, Renflexis: must have also failed Inflectra or Avsola.

2. Code J2327 – INJECTION, RISANKIZUMAB-RZAA, IV (SKYRIZI) 1 MG: For the treatment of Crohn’s Disease and Ulcerative Colitis. PA required. Reserved for treatment failure to tumor necrosis factor (TNF) inhibitors AND have tried and failed ustekinumab. Must be prescribed by gastroenterologist.
3. Code J3358 – INJECTION, USTEKINUMAB, FOR IV INJECTION, (STELARA) 1 MG, Code Q5099 – INJECTION, USTEKINUMAB-STBA, BIOSIMILAR, (STEQEYMA) 1 MG, Code Q5100 – INJECTION, USTEKINUMAB-KFCE BIOSIMILAR, (YESINTEK) 1 MG, Code Q5137 – INJECTION, WEZLANA SUB CU, (WEZLANA) 1 MG, Code Q5138 – INJECTION, WEZLANA IV, (WEZLANA) 1 MG, Code Q9996 – INJECTION, USTEKINUMAB-TTWE PYZCHIVA SC, (PYZCHIVA) 1 MG, Code Q9998 – INJECTION, USTEKINUMAB-AEKN SELARSDI, (SELARSDI) 1 MG:

For the treatment of Crohn’s Disease: PA required. Reserved for treatment failure to tumor necrosis factor (TNF) inhibitors. Must be prescribed by gastroenterologist.

a) Fill history or documentation of treatment failure to tumor necrosis factor (TNF) inhibitors.
AND
b) For non-preferred products Selarsdi, Otulfi, Yesintek, Imuldosa, Steqeyma, must have also failed Stelara, Wezlana, Pyzchiva, or Starjemza.

For the treatment of Ulcerative Colitis: PA required. Reserved for treatment failure to tumor necrosis factor (TNF) inhibitors. Must be prescribed by gastroenterologist.

a) Documented diagnosis of moderate to severe ulcerative colitis and fill history or documentation of treatment failure to tumor necrosis factor (TNF) inhibitors.
AND
b) For non-preferred products Selarsdi, Otulfi, Yesintek, Imuldosa, Steqeyma: must have also failed Stelara, Wezlana, Pyzchiva, or Starjemza.

4. Code Q5134 – INJECTION, NATALIZUMAB-SZTN (TYRUKO) 1 MG: For the treatment of Crohn’s Disease. PA required. Reserved for patients with contraindication to ALL other agents. Must be prescribed by gastroenterologist.

a) Documentation showing contraindication to ALL other agents and a negative anti-JCV antibody detection test result.

5. Code J0129 – INJECTION, ABATACEPT, (ORENCIA) 10 MG: Update to allow for exceptions for patients with high anticitrullinated protein antibodies (ACPA) positive disease. PA required. Must be initiated by a rheumatologist. Reserved for treatment of rheumatoid arthritis and must meet one of the following:

• Treatment failure/documented intolerance to Adalimumab, Etanercept, Infliximab, Rituximab (or biosimilars), Sarilumab, OR
• Patients with:
  a) Anticitrullinated protein antibodies (ACPA) level of greater than 59 EU/mL, rheumatoid factor (RF) between 60-100 IU/mL, or nontuberculous mycobacterial lung disease OR contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease
  AND
  b) Who have treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Leflunomide, Hydroxychloroquine, Sulfasalazine,Azathioprine).

6. Code 91323 – INTRAMUSCULAR, SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, MRNA-LNP, 10 MCG/0.2 ML DOSAGE: No PA required for Medicare benefit.

7. Code 90714 – INTRAMUSCULAR, TD VACCINE PRSRV FREE 7 YRS OR OLDER: No PA required for Medicare benefit. When administered to individuals 7 years or older.

8. Code 90632– INTRAMUSCULAR, HEPA VACCINE ADULT DOSE: No PA required for Medicare benefit.

9. Code J3299 – INJECTION, TRIAMCINOLONE ACETONIDE, (XIPERE) 1 MG, Code J3300 – INJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE FREE, 1 MG, Code J3301 – INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG, Code J3302 – INJECTION, TRIAMCINOLONE DIACETATE, PER 5 MG, Code J3303 – INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5 MG, Code J3304 – INJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE-FREE, EXTENDED-RELEASE, MICROSPHERE FORMULATION, 1 MG: No PA required for Medicare benefit.

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