Provider Alerts

Effective June 19, 2023, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

1. Code J9035 – INJECTION, BEVACIZUMAB (Avastin), 10 MG: PA required. Must meet ALL of the following: No concurrent ocular or periocular infection. Reserved for patients aged 18 years or older. Eye condition appropriate for treatment, including Diabetic macular edema, Macular edema following retinal vein occlusion, Myopic choroidal neovascularization, Neovascular age-related macular degeneration OR Indication approved by FDA or society guidelines. Limited to one dose per eye every four weeks.
2. Code J2778 – INJECTION, RANIBIZUMAB (Lucentis), 0.1 MG, J2779 – INJ RANIBIZUMAB VIA IVT IMPLANT (SUSVIMO), 0.1 MG, Q5124- INJECTION, RANIBIZUMAB-NUNA BIOSIMILAR, (BYOOVIZ), 0.1 MG: PA required. Must meet ALL of the following: No concurrent ocular or periocular infection. Reserved for patients aged 18 years or older AND must have failed or had clinically significant adverse effects to bevacizumab. Eye condition appropriate for treatment, including Diabetic macular edema, Diabetic retinopathy, Macular edema following retinal vein occlusion, Myopic choroidal neovascularization, Neovascular wet or exudative age-related macular degeneration, Polypoid choroidal vasculopathy with active juxtafoveal or subfoveal lesions OR Indication approved by FDA or society guidelines. Limited to one dose per eye every four weeks for ranibizumab injection and every 24 weeks (6 months) for Susvimo implant.
3. Code J0178 – INJECTION, AFLIBERCEPT (Eylea), 1 MG: PA required. Must meet ALL of the following: No concurrent ocular or periocular infection. Reserved for patients aged 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. Eye condition appropriate for treatment, including Diabetic macular edema, with or without diabetic retinopathy, Macular edema following central or branch vein occlusion, Neovascular (wet or exudative) age-related macular degeneration OR Indication approved by FDA or society guidelines. Limited to one dose per eye every 4 weeks.
4. Code J2777 – Injection, Faricimab-SVOA (Vabysmo), 0.1 mga: PA required. Must meet ALL of the following: No concurrent ocular or periocular infection. Reserved for patients aged 18 years or older AND must have failed or had clinically significant adverse effects to bevacizumab. Eye condition appropriate for treatment, including Neovascular (wet or exudative) age-related macular degeneration, Diabetic macular edema, with or without diabetic retinopathy OR Indication approved by FDA or society guidelines. Limited to not exceed standard dosing per FDA package insert.
5. Code J0179 – INJECTION, BROLUCIZUMAB-DBLL (Beovu), 1 MG: PA Required. Must meet ALL of the following: No concurrent ocular or periocular infection. Reserved for patients 18 years or older AND must have failed or had clinically significant adverse effects to bevacizumab. Eye condition appropriate for treatment, including Neovascular (wet or exudative) age-related macular degeneration, Diabetic macular edema, with or without diabetic retinopathy OR Indication approved by FDA or society guidelines. Limited to not exceed standard dosing per FDA package insert.
6. Code – J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, (Triesence), 10MG, J3299 – INJECTION TRIAMCINOLONE ACETONIDE (Xipere) 1 MG: No Restrictions.
7. Code J7312 – INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT (Ozurdex), 0.1 MG: PA required. Indicated for ALL of the following: No concurrent ocular or periocular infection. Reserved for patients aged 18 years or older. Eye condition appropriate for treatment, including Diabetic macular edema, Macular edema following retinal vein occlusion, Non-infectious uveitis affecting posterior segment of the eye OR Indication approved by FDA or society guidelines. Limited to not exceed more than one dose per eye every four (4) months.
8. Code J7313 – INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT (Iluvien), 0.01 MG, J7314 – INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT (Yutiq), 0.01 MG: PA required. Indicated for ALL of the following: No concurrent ocular or periocular infection. Reserved for patients aged 18 years or older. Eye condition appropriate for treatment, including Macular edema, Diabetic macular edema, Uveitis, OR Indication approved by FDA or society guidelines. Limited to not exceed more than one dose per eye every 12 months for Iluvien, and 36 months for Yutiq.
9. Code J7311 INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT (Retisert), 0.01 MG: PA required. Indicated for ALL of the following: No concurrent ocular or periocular infection. Reserved for patients aged 12 years or older AND must have failed or had clinically significant adverse effects to Ozurdex, Iluvien, or Yutiq unless patient is younger than 18 years of age. Eye condition appropriate for treatment, including Macular edema, Diabetic macular edema, Uveitis, OR Indication approved by FDA or society guidelines. Limited to not exceed more than one dose per eye every 30 months for Retisert.
10. Code J9000 – INJECTION DOXORUBICIN HCL 10 MG, J9040 – INJECTION
    BLEOMYCIN SULFATE 15 UNIT, J9045 – INJECTION CARBOPLATIN 50 MG, J9060 – INJECTION CISPLATIN POWDER OR SOLUTION 10 MG, J9070 –
    CYCLOPHOSPHAMIDE 100 MG, J9100 – INJECTION CYTARABINE 100 MG, J9130 – DACARBAZINE 100 MG, J9181 – INJECTION ETOPOSIDE 10 MG, J9190 – INJECTION FLUOROURACIL 500 MG, J9201 – INJECTION GEMCITABINE HCL NOS 200 MG, J9202 – GOSERELIN ACETATE IMPLANT 3.6 MG, J9217 – LEUPROLIDE ACETATE 7.5 MG, J9351 – INJECTION TOPOTECAN 0.1 MG, J9360 – INJECTION VINBLASTINE SULFATE 1 MG, J9370 – VINCRISTINE SULFATE 1 MG, J9390 – INJ VINORELBINE TARTRATE 10 MG: No PA required if the code is used for chemotherapy and the provider is within the network.
11. Code J9358 – INJECTION, FAM-TRASTUZUMAB DERUXTECAN-NXKI, 1MG: PA required. Must meet medical necessity.

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