Code	Description	PA Coverage Criteria
J9144	INJECTION, DARATUMUMAB, 10MG AND HYALURONIDASE-FIHJ	Approval is determined by medical necessity criteria
Q5108	INJECTION, PEGFILGRASTIMJMDB, BIOSIMILAR, (FULPHILA), 0.5 MG
Q5110	INJECTION, FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM), 1 MCG
Q5111	INJECTION, PEGFILGRASTIMCBQV, BIOSIMILAR, (UDENYCA), 0.5 MG
Q5101	INJECTION, FILGRASTIM-SNDZ, BIOSIMILAR, (ZARXIO), 1 MCG
J1447	INJECTION, TBO-FILGRASTIM, 1 MICROGRAM
J2506	INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG
J1442	INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM	Reserved for documentation of treatment failure of a 1st line short-acting G-CSF: filgrastim-sndz (Zarxio), tbo-filgrastim (Granix), or filgrastim-aafi (Nivestym).
Q5120	INJECTION, PEGFILGRASTIMBMEZ, BIOSIMILAR, (ZIEXTENZO), 0.5 MG	Reserved for documentation of treatment failure of a 1st line long-acting G-CSF: pegfilgrastim (Neulasta, Neulasta Onpro), pegfilgrastim-jmdb (Fulphila), or pegfilgrastimcbqv (Udenyca).
Q5122	INJECTION, PEGFILGRASTIMAPGF, BIOSIMILAR, (NYVEPRIA), 0.5 MG
J1756	INJECTION, IRON SUCROSE, 1 MG	Reserved for patients with one or more of the following: a) Absolute iron deficiency anemia with a ferritin <30μg/L or TSAT <20% with treatment failure or inability to tolerate oral iron. b) Chronic kidney disease with or without dialysis with ferritin < 500μg/L and TSAT <30% with treatment failure or inability to tolerate oral iron for non-dialysis patients. c) Chemotherapy-induced anemia with ferritin 30-500μg/L or TSAT <50% in patients receiving ESAs. Ferritin must not exceed 800μg/L, and TSAT must not be ≥50%. Note: Code J1756 is limited to 1,200 mg per treatment cycle.
Q0138	INJECTION, FERUMOXYTOL, FOR TREATMENT OF IDA, 1 MG (NONESRD USE)
Q0139	INJECTION, FERUMOXYTOL, FOR TREATMENT OF IDA, 1 MG (FOR ESRD ON DIALYSIS)
Q5105	INJECTION, EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR ESRD ON DIALYSIS), 100 UNITS	Reserved for patients who have Hemoglobin (Hgb) 20% or serum ferritin > 100 ng/ml at initiation. Hgb should be checked monthly and is not to exceed 11 g/dl. Authorization is for 12 months at a time. For renewal, Hgb must be below 11 g/dL.
Q5106	INJECTION, EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS
J0885	INJECTION, EPOETIN ALFA (FOR NON-ESRD USE), 1000 UNITS	Reserved for patients who have Hemoglobin (Hgb) 20% or serum ferritin > 100 ng/ml at initiation AND treatment failure or contraindication to Retacrit. Hgb should be checked monthly and is not to exceed 11 g/dl. When initiating therapy for anemia due to CKD, cumulative weekly dosing does not exceed the target range of 50 to 100 units/kg 3 times a week (300 units/kg weekly). Authorization is for 12 months at a time. For renewal, Hgb must be below 11 g/dL.
Q4081	INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)