Medical Drug Policies
The drugs listed below have corresponding medical drug policies that contain coverage criteria for how these drugs are covered by Aspirus Health Plan when billed under the member’s medical benefit. Medical drug policies are reviewed and approved by a Pharmacy and Therapeutics Committee and are subject to change. Authorization requests should be submitted and approved prior to dispensing/administering.
Find Medical Injectable Drug Prior Authorization Resources and forms to request authorizations on our Pharmacy page.
Medicare Policies
The coverage criteria contained in the policy may not apply to Aspirus Health Plan Medicare products if Medicare requires different coverage criteria. If Medicare requires different coverage criteria, the applicable NCD or LCD will apply.
Some medical injectable products are dosed based on patient weight and therefore may require minor dose adjustments during the duration of the authorization. Aspirus allows for additional units to be added to the products listed in the Appendix of the Weight Based Dose Rounding Policy.
Medical Drug Policies
Drug Name | HCPCS Code | Therapeutic Class |
---|---|---|
Abecma | Q2055 | Oncology |
Abraxane | J9264 | Oncology |
Actemra | J3262 | Inflammatory Conditions |
Acthar Gel | J0801 | Rare/Misc Conditions |
Adakveo | J0791 | Hematology |
Adcetris | J9042 | Oncology |
Adstiladrin | J9029 | Oncology |
Aduhelm | J0172 | Rare/Misc Conditions |
Adzynma | J7171 | Hematology |
Aldurazyme | J1931 | Enzyme Replacement |
Alimta | J9305 | Oncology |
Aliqopa | J9057 | Oncology |
Alymsys | Q5126 | Oncology/Biosimilar |
Amondys 45 | J1426 | Rare/Misc Conditions |
Amtagvi | NOC | Oncology |
Amvuttra | J0225 | Rare/Misc Conditions |
Anktiva | NOC | Oncology |
Aralast NP | J0256 | Rare/Misc Conditions |
Arzerra | J9302 | Oncology |
Asparlas | J9118 | Oncology |
Avastin | J9035 | Oncology/Biosimilar |
Azedra | A9590 | Oncology |
Bavencio | J9023 | Oncology |
Beleodaq | J9032 | Oncology |
Benlysta | J0490 | Inflammatory Conditions |
Beovu | J0179 | Ophthalmic Agents |
Beqvez | NOC | Hematology |
Berinert | J0597 | Hereditary Angioedema |
Besponsa | J9229 | Oncology |
Blenrep | J9037 | Oncology |
Blincyto | J9039 | Oncology |
Breyanzi | Q2054 | Oncology |
Brineura | J0567 | Rare/Misc Conditions |
Briumvi | J2329 | Multiple Sclerosis |
Byooviz | Q5124 | Ophthalmic Agents |
Cablivi | C9047 | Hematology |
Carvykti | Q2056 | Oncology |
Casgevy | NOC | Hematology |
Cerezyme | J1786 | Enzyme Replacement |
Chorionic Gonadotropin | J0725 | Infertility |
Cimerli | Q5128 | Ophthalmic Agents |
Cimzia | J0717 | Inflammatory Conditions |
Cinqair | J2786 | Immunologicals |
Cinryze | J0598 | Hereditary Angioedema |
Columvi | J9286 | Oncology |
Cortrophin Gel | J0802 | Rare/Misc Conditions |
Cosela | J1448 | Oncology |
Cosentyx IV | J3247 | Inflammatory Conditions |
Crysvita | J0584 | Rare/Misc Conditions |
Cyramza | J9308 | Oncology |
Danyelza | J9348 | Oncology |
Darzalex | J9145 | Oncology |
Darzalex Faspro | J9144 | Oncology |
Duopa | J7340 | Rare/Misc Conditions |
Durolane | J7318 | Viscosupplement |
Elahere | J9063 | Oncology |
Elaprase | J1743 | Enzyme Replacement |
Elelyso | J3060 | Enzyme Replacement |
Elevidys | J1413 | Rare/Misc Conditions |
Elfabrio | J2508 | Rare/Misc Conditions |
Elrexfio | J1323 | Oncology |
Elzonris | J9269 | Oncology |
Empliciti | J9176 | Oncology |
Enhertu | J9358 | Oncology |
Enjaymo | J1302 | Hematology |
Entyvio | J3380 | Inflammatory Conditions |
Epkinly | J9321 | Oncology |
Epogen | J0885 | Hematology/Biosimilar |
Erbitux | J9055 | Oncology |
Erwinaze | J9019 | Oncology |
Evenity | J3111 | Rare/Misc Conditions |
Evkeeza | J1305 | Rare/Misc Conditions |
Exondys 51 | J1428 | Rare/Misc Conditions |
Eylea | J0178 | Ophthalmic Agents |
Eylea HD | J0177 | Ophtalmic Agents |
Fabrazyme | J0180 | Enzyme Replacement |
Fasenra | J0517 | Immunologicals |
Firazyr | J1744 | Hereditary Angioedema |
Folotyn | J9307 | Oncology |
Fulphila | Q5108 | Hematology/Biosimilar |
Fyarro | J9331 | Oncology |
Fylnetra | Q5130 | Hematology/Biosimilar |
Gamifant | J9210 | Rare/Misc Conditions |
Gazyva | J9301 | Oncology |
Gel-One | J7326 | Viscosupplement |
Gelsyn 3 | J7328 | Viscosupplement |
GenVisc 850 | J7320 | Viscosupplement |
Givlaari | J0223 | Hematology |
Glassia | J0257 | Rare/Misc Conditions |
Granix | J1447 | Hematology/Biosimilar |
Haegarda | J0599 | Hereditary Angioedema |
Hemgenix | J1411 | Hematology |
Hemlibra | J7170 | Hematology |
Herceptin | J9355 | Oncology/Biosimilar |
Herceptin Hylecta | J9356 | Oncology |
Herzuma | Q5113 | Oncology/Biosimilar |
Hyalgan | J7321 | Viscosupplement |
Hymovis | J7322 | Viscosupplement |
iDose TR | J7355 | Ophthalmic Agents |
Ilaris | J0638 | Inflammatory Conditions |
Ilumya | J3245 | Inflammatory Conditions |
Imcivree | NOC | Rare/Misc Conditions |
Imdelltra | C9170 | Oncology |
Imfinzi | J9173 | Oncology |
Imjudo | J9347 | Oncology |
Imlygic | J9325 | Oncology |
Istodax | J9319 | Oncology |
Izervay | J2782 | Ophthalmic Agents |
Jelmyto | J9281 | Oncology |
Jemperli | J9272 | Oncology |
Jevtana | J9043 | Oncology |
Kadcyla | J9354 | Oncology |
Kalbitor | J1290 | Hereditary Angioedema |
Kanuma | J2840 | Enzyme Replacement |
Keytruda | J9271 | Oncology |
Kimmtrak | J9274 | Oncology |
Kisunla | NOC | Rare/Misc Conditions |
Krystexxa | J2507 | Rare/Misc Conditions |
Kymriah | Q2042 | Oncology |
Kyprolis | J9047 | Oncology |
Lamzede | J0217 | Rare/Misc Conditions |
Lanreotide | J1932 | Somatostatin Analog |
Lartruvo | J9285 | Oncology |
Lemtrada | J0202 | Multiple Sclerosis |
Lenmeldy | NOC | Rare/Misc Conditions |
Leqembi | J0174 | Rare/Misc Conditions |
Leqvio | J1306 | Rare/Misc Conditions |
Libtayo | J9119 | Oncology |
Loqtorzi | J3263 | Oncology |
Lucentis | J2778 | Ophthalmic Agents |
Lumizyme | J0221 | Enzyme Replacement |
Lumoxiti | J9313 | Oncology |
Lunsumio | J9350 | Oncology |
Lutathera | A9513 | Oncology |
Luxturna | J3398 | Rare/Misc Conditions |
Lyfgenia | J3394 | Hematology |
Margenza | J9353 | Oncology |
Mepsevii | J3397 | Enzyme Replacement |
Monjuvi | J9349 | Oncology |
Monovisc | J7327 | Viscosupplement |
Mylotarg | J9203 | Oncology |
Naglazyme | J1458 | Enzyme Replacement |
Neupogen | J1442 | Hematology/Biosimilar |
Nexviazyme | J0219 | Enzyme Replacement |
Nipent | J9268 | Oncology |
Nivestym | Q5110 | Hematology/Biosimilar |
Novarel | J0725 | Infertility |
Nplate | J2796 | Hematology |
Nucala | J2182 | Immunologicals |
Nulibry | NOC | Rare/Misc Conditions |
Ocrevus | J2350 | Multiple Sclerosis |
Ogivri | Q5114 | Oncology/Biosimilar |
Omisirge | NOC | Oncology |
Omvoh | J2267 | Inflammatory Conditions |
Oncaspar | J9266 | Oncology |
Onivyde | J9205 | Oncology |
Onpattro | J0222 | Rare/Misc Conditions |
Ontruzant | Q5112 | Oncology/Biosimilar |
Opdivo | J9299 | Oncology |
Opdualag | J9298 | Oncology |
Orencia | J0129 | Inflammatory Conditions |
Orthovisc | J7324 | Viscosupplement |
Ovidrel | NOC | Infertility |
Oxlumo | J0224 | Rare/Misc Conditions |
Paclitaxel (American Regent) | J9259 | Oncology |
Paclitaxel (Teva) | J9258 | Oncology |
Padcev | J9177 | Oncology |
Panhematin | J1640 | Hematology/Biosimilar |
Pedmark | J0208 | Oncology |
Pemetrexed (Accord) | J9296 | Oncology |
Pemetrexed (Bluepoint) | J9322 | Oncology |
Pemetrexed Ditromethamine | J9323 | Oncology |
Pemetrexed (Hospira) | J9294 | Oncology |
Pemetrexed (Sandoz) | J9297 | Oncology |
Pemetrexed (Teva) | J9314 | Oncology |
Pemfexy | J9304 | Oncology |
Pemrydi RTU | J9324 | Oncology |
Perjeta | J9306 | Oncology |
Phesgo | J9316 | Oncology |
PiaSky | NOC | Rare/Misc Conditions |
Pluvicto | A9607 | Oncology |
Polivy | J9309 | Oncology |
Pombiliti | J1203 | Rare/Misc Conditions |
Portrazza | J9295 | Oncology |
Poteligeo | J9204 | Oncology |
Pregnyl | J0725 | Infertility |
Procrit | J0885 | Hematology/Biosimilar |
Prolastin | J0256 | Rare/Misc Conditions |
Proleukin | J9015 | Oncology |
Provenge | Q2043 | Oncology |
Qalsody | J1304 | Rare/Misc Conditions |
Radicava | J1301 | Rare/Misc Conditions |
Reblozyl | J0896 | Hemotology |
Releuko | Q5125 | Hematology/Biosimilar |
Remicade | J1745 | Inflammatory Conditions/Biosimilar |
Renflexis | Q5104 | Inflammatory Conditions/Biosimilar |
Revcovi | NOC | Enzyme Replacement |
Riabni | Q5123 | Oncology/Biosimilar |
Rituxan | J9312 | Oncology/Biosimilar |
Rituxan Hycela | J9311 | Oncology |
Rivfloza | NOC | Rare/Misc Conditions |
Roctavian | J1412 | Hematology |
Rolvedon | J1449 | Hematology |
Romidepsin | J9318 | Oncology |
Ruconest | J0596 | Hereditary Angioedema |
Rybrevant | J9061 | Oncology |
Rylaze | J9021 | Oncology |
Ryplazim | J2998 | Hematology |
Rystiggo | J9333 | Rare/Misc Conditions |
Rytelo | NOC | Oncology |
Ryzneuta | J9361 | Hematology/Biosimilar |
Sajazir | J1744 | Hereditary Angioedema |
Sandostatin | J2353 | Somatostatin Analog |
Saphnelo | J0491 | Rare/Misc Conditions |
Sarclisa | J9227 | Oncology |
Scenesse | J7352 | Rare/Misc Conditions |
Simponi Aria | J1602 | Inflammatory Conditions |
Skyrizi IV | J2327 | Inflammatory Conditions |
Skysona | NOC | Rare/Misc Conditions |
Sodium Hyaluronate 1% (Teva) | NOC | Viscosupplement |
Soliris | J1300 | Rare/Misc Conditions |
Spevigo | J1747 | Inflammatory Conditions |
Spinraza | J2326 | Rare/Misc Conditions |
Spravato | G2082, G2083 | Rare/Misc Conditions |
Stelara IV | J3358 | Inflammatory Conditions |
Stelara SC | J3357 | Inflammatory Conditions |
Stimufend | Q5127 | Hematology/Biosimilar |
Sunlenca | J1961 | Rare/Misc Conditions |
Supartz FX | J7321 | Viscosupplement |
Susvimo | J2779 | Ophthalmic Agents |
Syfovre | J2781 | Ophthalmic Agents |
Sylvant | J2860 | Oncology |
SynoJoynt | J7331 | Viscosupplement |
Synribo | J9262 | Oncology |
Takhzyro | J0593 | Hereditary Angioedema |
Talvey | J3055 | Oncology |
Tecartus | Q2053 | Oncology |
Tecelra | NOC | Oncology |
Tecentriq | J9022 | Oncology |
Tecvayli | J9380 | Oncology |
Tegsedi | NOC | Rare/Misc Conditions |
Tepezza | J3241 | Rare/Misc Conditions |
Tevimbra | J9329 | Oncology |
Tezspire | J2356 | Immunologicals |
Tivdak | J9273 | Oncology |
Tofidence | Q5133 | Inflammatory Conditions |
Tremfya | J1628 | Inflammatory Conditions |
Triluron | J7332 | Viscosupplement |
TriVisc | J7329 | Viscosupplement |
Trodelvy | J9317 | Oncology |
Trogarzo | J1746 | Rare/Misc Conditions |
Tyenne | NOC | Inflammatory Conditions |
Tysabri | J2323 | Multiple Sclerosis |
Tzield | J9381 | Rare/Misc Conditions |
Ultomiris | J1303 | Rare/Misc Conditions |
Unituxin | J1246 | Oncology |
Uplizna | J1823 | Rare/Misc Conditions |
Vabysmo | J2777 | Ophthalmic Agents |
Valstar | J9357 | Oncology |
Vectibix | J9303 | Oncology |
Vegzelma | Q5129 | Oncology/Biosimilar |
Veopoz | J9376 | Enzyme Replacement |
Viltepso | J1427 | Rare/Misc Conditions |
Vimizim | J1322 | Enzyme Replacement |
Visco-3 | J7321 | Viscosupplement |
Vpriv | J3385 | Enzyme Replacement |
Vyepti | J3032 | Rare/Misc Conditions |
Vyjuvek | J3401 | Rare/Misc Conditions |
Vyondys 53 | J1429 | Muscular Dystrophy |
Vyvgart | J9332 | Rare/Misc Conditions |
Vyvgart Hytrulo | J9334 | Rare/Misc Conditions |
Vyxeos | J9153 | Oncology |
Wainua | NOC | Rare/Misc Conditions |
Xenpozyme | J0218 | Rare/Misc Conditions |
Xiaflex | J0775 | Rare/Misc Conditions |
Xolair | J2357 | Immunologicals |
Ycanth | J7354 | Rare/Misc Conditions |
Yervoy | J9228 | Oncology |
Yescarta | Q2041 | Oncology |
Yondelis | J9352 | Oncology |
Zaltrap | J9400 | Oncology |
Zemaira | J0256 | Rare/Misc Conditions |
Zepzelca | J9223 | Oncology |
Ziextenzo | Q5120 | Hematology/Biosimilar |
Zolgensma | J3399 | Rare/Misc Conditions |
Zulresso | J1632 | Rare/Misc Conditions |
Zynlonta | J9359 | Oncology |
Zynteglo | J3393 | Hematology |
Zynyz | J9345 | Oncology |