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Medical Drug Policies

The drugs listed below have corresponding medical drug policies that contain coverage criteria for how these drugs are covered by UCare when billed under the member’s medical benefit. Medical drug policies are reviewed and approved by UCare’s Pharmacy and Therapeutics Committee and are subject to change. Authorization requests should be submitted and approved prior to dispensing/administering.

Care Continuum, a subsidiary of Express Scripts, will review Medical Drug Prior Authorization requests for all UCare plans.

Submit an authorization request one of the following ways:

Medicare Policies:

The coverage criteria contained in the policy may not apply to UCare Medicare products if Medicare requires different coverage criteria. If Medicare requires different coverage criteria, the applicable NCD or LCD will apply. Find Medical Injectable Drug Prior Authorization Resources for each UCare health plan and forms to request authorizations on our Pharmacy page.

Drug Name HCPCS Code Therapeutic Class
Abecma - Medicaid, IFP Q2055 Oncology
Abecma - Medicare Q2055 Oncology
Abraxane - Medicaid, IFP J9264 Oncology
Abraxane - Medicare J9264 Oncology
Actemra J3262 Inflammatory Conditions
Adakveo J0791 Hematology
Adcetris J9042 Oncology
Aduhelm - IFP J0172 Neurology
Aduhelm - Medicaid J0172 Neurology
Aduhelm - Medicare J0172 Neurology
Aldurazyme J1931 Enzyme Replacement
Alimta J9305 Oncology
Aliqopa J9057 Oncology
Alymsys - Medicaid, IFP NOC Oncology/Biosimilar
Alymsys - Medicare NOC Oncology/Biosimilar
Amondys45 J1426 Rare/Misc Conditions
Amvuttra NOC Rare/Misc Conditions
Aralast NP J0256 Rare/Misc Conditions
Arzerra J9302 Oncology
Asparlas J9118 Oncology
Avastin - Medicaid, IFP J9035 Oncology/Biosimilar
Avastin - Medicare J9035 Oncology/Biosimilar
Azedra (Diagnostic and Therapeutic) A9590 Oncology
Bavencio J9023 Oncology
Beleodaq J9032 Oncology
Benlysta J0490 Inflammatory Conditions
Beovu - Medicaid, IFP J0179 Ophthalmic Agents
Beovu - Medicare J0179 Ophthalmic Agents
Berinert J0597 Hereditary Angioedema
Besponsa J9229 Oncology
Blenrep J9037 Oncology
Blincyto J9039 Oncology
Breyanzi - Medicaid, IFP Q2054 Oncology
Breyanzi - Medicare Q2054 Oncology
Brineura J0567 Rare/Misc Conditions
Byooviz - Medicaid, IFP Q5124 Ophthalmic Agents
Byooviz - Medicare Q5124 Ophthalmic Agents
Cablivi C9047 Hematology
Carvykti Q2056 Oncology
Cerezyme J1786 Enzyme Replacement
Chorionic Gonadotropin J0725 Infertility
Cimzia J0717 Inflammatory Conditions
Cinqair J2786 Immunologicals
Cinryze J0598 Hereditary Angioedema
Cortrophin Gel NOC Rare/Misc Conditions
Cosela J1448 Oncology
Crysvita J0584 Rare/Misc Conditions
Cyramza J9308 Oncology
Danyelza J9348 Oncology
Darzalex J9145 Oncology
Darzalex Faspro J9144 Oncology
Duopa J7340 Rare/Misc Conditions
Durolane - Medicaid, IFP J7318 Viscosupplement
Durolane - Medicare J7318 Viscosupplement
Elaprase J1743 Enzyme Replacement
Elelyso J3060 Enzyme Replacement
Elzonris J9269 Oncology
Empliciti J9176 Oncology
Enhertu J9358 Oncology
Enjaymo J1302 Hematology
Entyvio J3380 Inflammatory Conditions
Epogen - Medicaid, IFP J0885 Hematology/Biosimilar
Epogen - Medicare J0885 Hematology/Biosimilar
Erbitux J9055 Oncology
Erwinaze J9019 Oncology
Evenity J3111 Osteoporosis
Evkeeza J1305 Rare/Misc Conditions
Exondys 51 J1428 Rare/Misc Conditions
Eylea - Medicaid, IFP J0178 Ophthalmic Agents
Eylea - Medicare J0178 Ophthalmic Agents
Fabrazyme J0180 Enzyme Replacement
Fasenra J0517 Immunologicals
Firazyr J1744 Hereditary Angioedema
Folotyn J9307 Oncology
Fulphila - Medicaid, IFP Q5108 Hematology/Biosimilar
Fulphila - Medicare Q5108 Hematology/Biosimilar
Fyarro J9331 Oncology
Fylnetra - Medicaid, IFP NOC Hematology/Biosimilar
Fylnetra - Medicare NOC Hematology/Biosimilar
Gamifant J9210 Rare/Misc Conditions
Gazyva J9301 Oncology
Gel-One - Medicaid, IFP J7326 Viscosupplement
Gel-One - Medicare J7326 Viscosupplement
Gelsyn 3 - Medicaid, IFP J7328 Viscosupplement
Gelsyn 3 - Medicare J7328 Viscosupplement
GenVisc 850 - Medicaid, IFP J7320 Viscosupplement
GenVisc 850 - Medicare J7320 Viscosupplement
Givlaari J0223 Hematology
Glassia J0257 Rare/Misc Conditions
Granix - Medicaid, IFP J1447 Hematology/Biosimilar
Granix - Medicare J1447 Hematology/Biosimilar
Haegarda J0599 Hereditary Angioedema
Hemlibra J7170 Hematology
Herceptin J9355 Oncology/Biosimilar
Herceptin Hylecta J9356 Oncology
Herzuma Q5113 Oncology/Biosimilar
HP Acthar J0800 Rare/Misc Conditions
Hyalgan - Medicaid, IFP J7321 Viscosupplement
Hyalgan - Medicare J7321 Viscosupplement
Hymovis - Medicaid, IFP J7322 Viscosupplement
Hymovis - Medicare J7322 Viscosupplement
Ilaris J0638 Inflammatory Conditions
Ilumya J3245 Inflammatory Conditions
Imcivree NOC Rare/Misc Conditions
Imfinzi J9173 Oncology
Imlygic J9325 Oncology
Istodax J9319 Oncology
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
Krystexxa J2507 Rare/Misc Conditions
Kymriah - Medicaid & IFP Q2042 Oncology
Kymriah - Medicare Q2042 Oncology
Kyprolis J9047 Oncology
Lartruvo J9285 Oncology
Lemtrada J0202 Multiple Sclerosis
Leqvio J1306 Rare/Misc Conditions
Libtayo J9119 Oncology
Lucentis - Medicaid, IFP J2778 Ophthalmic Agents
Lucentis - Medicare J2778 Ophthalmic Agents
Lumizyme J0221 Enzyme Replacement
Lumoxiti J9313 Oncology
Lutathera A9513 Oncology
Luxturna J3398 Rare/Misc Conditions
Margenza J9353 Oncology
Mepsevii J3397 Enzyme Replacement
Monjuvi J9349 Oncology
Monovisc - Medicaid, IFP J7327 Viscosupplement
Monovisc - Medicare J7327 Viscosupplement
Mylotarg J9203 Oncology
Naglazyme J1458 Enzyme Replacement
Neupogen - Medicaid, IFP J1442 Hematology/Biosimilar
Neupogen - Medicare J1442 Hematology/Biosimilar
Nexviazyme J0219 Enzyme Replacement
Nipent J9268 Oncology
Nivestym - Medicaid, IFP Q5110 Hematology/Biosimilar
Nivestym - Medicare Q5110 Hematology/Biosimilar
Novarel J0725 Infertility
Nplate J2796 Hematology
Nucala J2182 Immunologicals
Nulibry NOC Rare/Misc Conditions
Nyvepria - Medicaid, IFP Q5122 Hematology/Biosimilar
Nyvepria - Medicare Q5122 Hematology/Biosimilar
Ocrevus J2350 Multiple Sclerosis
Ogivri Q5114 Oncology/Biosimilar
Oncaspar J9266 Oncology
Onivyde J9205 Oncology
Onpattro J0222 Rare/Misc Conditions
Ontruzant Q5112 Oncology/Biosimilar
Opdivo - Medicaid & IFP J9299 Oncology
Opdivo - Medicare J9299 Oncology
Opdualag J9298 Oncology
Orencia J0129 Inflammatory Conditions
Orthovisc - Medicaid, IFP J7324 Viscosupplement
Orthovisc - Medicare J7324 Viscosupplement
Ovidrel NOC Infertility
Oxlumo J0224 Rare/Misc Conditions
Padcev J9177 Oncology
Panhematin J1640 Hematology/Biosimilar
Pemetrexed NOC Oncology
Pemfexy J9304 Oncology
Pepaxto J9247 Oncology
Perjeta J9306 Oncology
Phesgo J9316 Oncology
Pluvicto A9607 Oncology
Polivy J9309 Oncology
Portrazza J9295 Oncology
Poteligeo J9204 Oncology
Pregnyl J0725 Infertility
Procrit - Medicaid, IFP J0885 Hematology/Biosimilar
Procrit - Medicare J0885 Hematology/Biosimilar
Prolastin J0256 Rare/Misc Conditions
Proleukin J9015 Oncology
Provenge Q2043 Oncology
Radicava J1301 Rare/Misc Conditions
Reblozyl J0896 Hematology
Releuko - Medicaid, IFP Q5125 Hematology/Biosimilar
Releuko - Medicare Q5125 Hematology/Biosimilar
Remicade - Medicaid IFP J1745 Inflammatory Conditions/Biosimilar
Remicade - Medicare J1745 Inflammatory Conditions/Biosimilar
Renflexis - Medicaid, IFP Q5104 Inflammatory Conditions/Biosimilar
Renflexis - Medicare Q5104 Inflammatory Conditions/Biosimilar
Revcovi NOC Enzyme Replacement
Riabni - Medicaid, IFP Q5123 Oncology/Biosimilar
Riabni - Medicare Q5123 Oncology/Biosimilar
Rituxan - Hycela J9311 Oncology
Rituxan - Medicaid IFP J9312 Oncology/Biosimilar
Rituxan - Medicare J9312 Oncology/Biosimilar
Romidepsin J9318 Oncology
Ruconest J0596 Hereditary Angioedema
Rybrevant J9061 Oncology
Rylaze J9021 Oncology
Ryplazim J2998 Hematology
Sajazir J1744 Hereditary Angioedema
Saphnelo J0491 Lupus
Sarclisa J9227 Oncology
Scenesse J7352 Rare/Misc Conditions
Simponi Aria J1602 Inflammatory Conditions
Skyrizi IV NOC Inflammatory Conditions
Soliris - Medicaid, IFP J1300 Rare/Misc Conditions
Soliris - Medicare J1300 Rare/Misc Conditions
Spinraza J2326 Rare/Misc Conditions
Spravato S0013 (Medicaid, IFP), G2082 (Medicare) Rare/Misc Conditions
Stelara (Intravenous) J3358 Inflammatory Conditions
Stelara (Subcutaneous) J3357 Inflammatory Conditions
Supartz FX - Medicaid, IFP J7321 Viscosupplement
Supartz FX - Medicare J7321 Viscosupplement
Susvimo - Medicaid J2779 Ophthalmic Agents
Susvimo - Medicare, IFP J2779 Ophthalmic Agents
Sylvant J2860 Oncology
Synojoynt - Medicaid, IFP J7331 Viscosupplement
Synojoynt - Medicare J7331 Viscosupplement
Synribo J9262 Oncology
Takhzyro J0593 Hereditary Angioedema
Tecartus - Medicaid, IFP Q2053 Oncology
Tecartus - Medicare Q2053 Oncology
Tecentriq J9022 Oncology
Tegsedi NOC Rare/Misc Conditions
Tepezza J3241 Rare/Misc Conditions
Tezspire J2356 Immunologicals
Tivdak J9273 Oncology
Tremfya J1628 Inflammatory Conditions
Triluron - Medicaid, IFP J7332 Viscosupplement
Triluron - Medicare J7332 Viscosupplement
TriVisc - Medicaid, IFP J7329 Viscosupplement
TriVisc - Medicare J7329 Viscosupplement
Trodelvy J9317 Oncology
Trogarzo J1746 Rare/Misc Conditions
Tysabri J2323 Multiple Sclerosis
Ultomiris J1303 Rare/Misc Conditions
Unituxin NOC Oncology
Uplizna J1823 Rare/Misc Conditions
Vabysmo - Medicaid, IFP J2777 Ophthalmic Agents
Vabysmo - Medicare J2777 Ophthalmic Agents
Valstar J9357 Oncology
Vectibix J9303 Oncology
Viltepso J1427 Rare/Misc Conditions
Vimizim J1322 Enzyme Replacement
Visco-3 - Medicaid, IFP J7321 Viscosupplement
Visco-3 - Medicare J7321 Viscosupplement
Vpriv J3385 Enzyme Replacement
Vyepti J3032 Rare/Misc Conditions
Vyondys 53 J1429 Muscular Dystrophy
Vyvgart J9332 Neurology
Vyxeos J9153 Oncology
Xiaflex J0775 Rare/Misc Conditions
Xolair - Medicaid, IFP J2357 Immunologicals
Xolair - Medicare J2357 Immunologicals
Yervoy J9228 Oncology
Yescarta - Medicaid, IFP Q2041 Oncology
Yescarta - Medicare Q2041 Oncology
Yondelis J9352 Oncology
Zaltrap J9400 Oncology
Zemaira J0256 Rare/Misc Conditions
Zepzelca J9223 Oncology
Zolgensma J3399 Rare/Misc Conditions
Zulresso J1632 Rare/Misc Conditions
Zynlonta J9359 Oncology