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2021 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 NOC Oncology
Abecma - Medicare NOC Oncology
Actemra J3262 Inflammatory Conditions
Adagen J2504 Enzyme Replacement
Adakveo J0791 Hematology
Adcetris J9042 Oncology
Aduhelm - Medicaid NOC Neurology
Aduhelm - Medicare, IFP NOC Neurology
Aldurazyme J1931 Enzyme Replacement
Alimta J9305 Oncology
Aliqopa J9057 Oncology
Amondys45 C9075 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
Berinert J0597 Hereditary Angioedema
Besponsa J9229 Oncology
Blenrep J9037 Oncology
Blincyto J9039 Oncology
Breyanzi - Medicaid, IFP C9076 Oncology
Breyanzi - Medicare C9076 Oncology
Brineura J0567 Rare/Misc Conditions
Cablivi C9047 Hematology
Cerezyme J1786 Enzyme Replacement
Chorionic Gonadotropin J0725 Infertility
Cimzia J0717 Inflammatory Conditions
Cinqair J2786 Immunologicals
Cinryze J0598 Hereditary Angioedema
Cosela C9078 Oncology
Crysvita J0584 Rare/Misc Conditions
Cyramza J9308 Oncology
Danyelza J9348 Oncology
Darzalex J9145 Oncology
Darzalex Faspro J9144 Oncology
Duopa J7340 Rare/Misc Conditions
Dupixent NOC Immunologicals
Elaprase J1743 Enzyme Replacement
Elelyso J3060 Enzyme Replacement
Elzonris J9269 Oncology
Empliciti J9176 Oncology
Enhertu J9358 Oncology
Entyvio J3380 Inflammatory Conditions
Epogen J0885 Hematology/Biosimilar
Erbitux J9055 Oncology
Erwinaze J9019 Oncology
Evenity J3111 Osteoporosis
Evkeeza C9079 Rare/Misc Conditions
Exondys 51 J1428 Rare/Misc Conditions
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
Gamifant J9210 Rare/Misc Conditions
Gazyva J9301 Oncology
Givlaari J0223 Rare/Misc Conditions
Glassia J0257 Rare/Misc Conditions
Granix - Medicaid, IFP 1 mcg - J1447, 5 mcg - J1446 Hematology/Biosimilar
Granix - Medicare 1 mcg - J1447, 5 mcg - J1446 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
Ilaris J0638 Inflammatory Conditions
Ilumya J3245 Inflammatory Conditions
Imcivree NOC Rare/Misc Conditions
Imfinzi J9173 Oncology
Imlygic J9325 Oncology
Jelmyto J9281 Oncology
Jemperli NOC Oncology
Jevtana J9043 Oncology
Kadcyla J9354 Oncology
Kalbitor J1290 Hereditary Angioedema
Kanuma J2840 Enzyme Replacement
Keytruda J9271 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
Libtayo J9119 Oncology
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
Mylotarg J9203 Oncology
Naglazyme J1458 Enzyme Replacement
Neupogen - Medicaid, IFP J1442 Hematology/Biosimilar
Neupogen - Medicare J1442 Hematology/Biosimilar
Nexviazyme NOC Enzyme Replacement
Nivestym - Medicaid, IFP Q5110 Hematology/Biosimilar
Nivestym - Medicare Q5110 Hematology/Biosimilar
Novarel J0725 Infertility
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
Orencia J0129 Inflammatory Conditions
Ovidrel NOC Infertility
Oxlumo J0224 Rare/Misc Conditions
Padcev J9177 Oncology
Panhematin J1640 Hematology/Biosimilar
Pepaxto C9080 Oncology
Perjeta J9306 Oncology
Phesgo J9316 Oncology
Polivy J9309 Oncology
Portrazza J9295 Oncology
Poteligeo J9204 Oncology
Pregnyl J0725 Infertility
Procrit J0885 Hematology/Biosimilar
Prolastin J0256 Rare/Misc Conditions
Provenge Q2043 Oncology
Radicava J1301 Rare/Misc Conditions
Reblozyl J0896 Hematology
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
Ruconest J0596 Hereditary Angioedema
Rybrevant NOC Oncology
Rylaze NOC Oncology
Saphnelo NOC Lupus
Sarclisa J9227 Oncology
Scenesse J7352 Rare/Misc Conditions
Simponi Aria J1602 Inflammatory Conditions
Soliris - Medicaid, IFP J1300 Rare/Misc Conditions
Soliris - Medicare J1300 Rare/Misc Conditions
Spinraza J2326 Rare/Misc Conditions
Spravato NOC Rare/Misc Conditions
Stelara (Intravenous) J3358 Inflammatory Conditions
Stelara (Subcutaneous) J3357 Inflammatory Conditions
Sylvant J2860 Oncology
Synribo J9262 Oncology
Takhzyro J0593 Hereditary Angioedema
Tecartus - Medicare Q2053 Oncology
Tecartus - Medicaid, IFP Q2053 Oncology
Tecentriq J9022 Oncology
Tegsedi NOC Rare/Misc Conditions
Tepezza J3241 Rare/Misc Conditions
Tremfya J1628 Inflammatory Conditions
Trodelvy J9317 Oncology
Trogarzo J1746 Rare/Misc Conditions
Tysabri J2323 Multiple Sclerosis
Ultomiris J1303 Rare/Misc Conditions
Unituxin NOC Oncology
Uplinza J1823 Rare/Misc Conditions
Vectibix J9303 Oncology
Viltepso J1427 Rare/Misc Conditions
Vimizim J1322 Enzyme Replacement
Vpriv J3385 Enzyme Replacement
Vyepti J3032 Rare/Misc Conditions
Vyondys 53 J1429 Muscular Dystrophy
Xiaflex J0775 Rare/Misc Conditions
Xolair - Medicaid, IFP J2357 Immunologicals
Xolair - Medicare J2357 Immunologicals
Yervoy J9228 Oncology
Yescarta Q2041 Oncology
Zaltrap J9400 Oncology
Zemaira J0256 Rare/Misc Conditions
Zepzelca J9223 Oncology
Zolgensma J3399 Rare/Misc Conditions
Zulresso J1632 Rare/Misc Conditions
Zynlonta NOC Oncology