24-488 Medical Medication Prior Authorization Changes

C9160

Injection, daxibotulinumtoxina-lanm, 1 unit

Daxxify^®

C9161

Injection, aflibercept HD, 1 mg

Eylea^®

C9162

Injection, avacincaptad pegol, 0.1 mg

Izervay^®

C9163

Injection, talquetamab-tgvs, 0.25 mg

Talvey^TM

C9165

Injection, elranatamab-bcmm, 1 mg

Elrexfio^TM

J0217

Injection, velmanase alfa-tycv, 1 mg

Lamzede^®

J1246

N/A

Unituxin^®

J1304

Injection, tofersen, 1 mg

Qalsody^®

J1412

Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes

Roctavian^®

J1413

Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose

Elevidys^TM

J2508

Injection, pegunigalsidase alfa-iwxj, 1 mg

Elfabrio^®

J3401

Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml

Vyjuvek^TM

J9286

Injection, glofitamab-gxbm, 2.5 mg

Columvi^TM

J9321

Injection, epcoritamab-bysp, 0.16 mg

Epkinly^TM

J9324

Injection, pemetrexed (Pemrydi RTU), 10 mg

Pemrydi RTU^®

J9333

Injection, rozanolixizumab-noli, 1 mg

Rystiggo^®

J9334

Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc

Vyvgart^® Hytrulo

Q5132

Injection, adalimumab-afzb (Abrilada), biosimilar, 10 mg

Abrilada^®

C9166

Injection, secukinumab, IV, 1 mg

Cosentyx^®

C9167

Injection, apadamtase alfa, 10 units

Adzynma^TM

C9168

Injection, mirikizumab-mrkz, 1 mg

Omvoh^TM

J0177

Injection, aflibercept HD, 1 mg

Eylea HD^®

J0589

Injection, daxibotulinumtoxina-lanm, 1 unit

Daxxify^®

J1203

Injection, cipaglucosidase alfa-atga, 5 mg

Pombiliti^TM

J1323

Injection, elranatamab-bcmm, 1 mg

Elrexfio^TM

J2277

Injection, motixafortide, 0.25 mg

Aphexda^®

J2782

Injection, avacincaptad pegol, 0.1 mg

Izervay^®

J3055

Injection, talquetamab-tgvs, 0.25 mg

Talvey^TM

J9376

Injection, pozelimab-bbfg, 1 mg

Veopoz^TM

Q5133

Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mg

Tofidence^TM

Q5134

Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mg

Tyruko^®

Benlysta^®

J0490, injection, belimumab, 10 mg

• Medi-Cal: change from ages 0 ­– 20 only to require prior authorization for all ages.
• Commercial/Ambetter: new for all members.

Trodelvy^®

J9317, Injection, sacituzumab govitecan-hziy, 2.5 mg

Casgevy^TM

HCPCS unassigned; J3590, Unclassified biologicals

Blenrep

J9037, injection, belantamab mafodotin-blmf, 0.5 (discontinued)

Feraheme

Q0138, Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) (discontinued)

Makenna

J1726, Injection, hydroxyprogesterone caproate, (makena), 10 mg

Sunlenca^®

J3490, injection, lenacapavir for the treatment of human immunodeficiency virus type 1

• Per All Plan Letter 20-020, HIV drugs are currently “carved out” of the managed care delivery system. If billed on medical and institutional claims, these drugs will process and be adjudicated through the California Medicaid Management Information System
  (CA-MMIS), a Medi-Cal Fee-For-Service (FFS) Fiscal Intermediary. If billed on pharmacy claims, these drugs will process through Medi-Cal Rx, and be adjudicated by Magellan.