Download 2016-17 Preauthorization List - Effective 7-1-16

UK-HMO
2016/17 PRIOR PLAN APPROVAL LIST
Phone: (866) 776-4793
(Effective 7-1-16)
The following Prior Plan Approval List represents services that require approval before the service is rendered. Failure to obtain prior
plan approval results in 100% penalty. No retro-authorizations are allowed.
Services
DME
 Bone Growth Stimulator: Electrical or Ultrasound
 External (Portable) Continuous Insulin Infusion
Pump
 Microprocessor Controlled Lower Limb Prosthesis


 Pneumatic Pressure Device with Calibrated Pressure
PROSTHETICS: Electronic or externally powered and
select other prosthetics


Communication Assisting/Speech Generating Devices
Functional Electrical Stimulation (FES); Threshold
Electrical Stimulation (TES)
Oscillatory Devices for Airway Clearance including
High Frequency Chest
Power Wheeled Mobility Devices
Standing Frame




Long-term Acute Care
Organ transplants/blood and marrow transplants

Physical rehabilitation facility admissions

Skilled Nursing Facility (SNF) admissions


Hospital inpatient admissions
Mental health and substance abuse facility
inpatient, partial hospital and intensive outpatient
services
Orthotics — professionally fitted braces and splints
costing more than $750
Prosthetics — artificial limbs

Procedures, tests and services

Abdominoplasty




Cochlear implant



Benign skin lesion removal (Auths not required for
UK Providers)
Breast reduction/augmentation (Breast
reconstruction procedures needs no precert with
diagnosis of cancer)
*Hyperbaric Therapy
Molecular Diagnostic/Genetic Testing*
Non-participating Physician/Facility Requests
Accidental dental and general anesthesia benefit
(except anesthesia associated with wisdom teeth
removal)
Blepharoplasty





Plastic or cosmetic surgery
Sclerotherapy (except stab phlebectomies)


Medication Preauthorization List (see page 2)
Neuropsychological testing
Oral surgery (except wisdom teeth removal and
associated anesthesia)
Rhinoplasty
Septoplasty


Speech Therapy
Temporomandibular joint (TMJ) procedures

Surgery for snoring or sleep apnea (e.g. UPPP)

Radiology
 Open MRIs outside UK or Samaritan Hospital (no open MRI at these facilities)
 Coronary CT angiography
1
UK-HMO Specialty Pharmacy Medical Management Drug List – Effective 7-1-2016
CODE
90281
90283
90284
90378
C9257
J0129
J0178
J0180
J0202
J0205
J0220
J0221
J0256
J0257
J0490
J0585
J0586
J0587
J0588
J0596
J0597
J0598
J0800
J0881
J0882
J0885
GENERIC NAME
Immune globulin, IM
Immune globulin
Immune globulin 100mg SQ
Palivizumab 50mg
Bevacizumab 0.25mg (J9035 is
for 10 mg)
Abatacept 10mg
Afibercept 1mg
Agalsidase beta 1 mg
Alemtuzmab
TRADE
CODE
TRADE
IgIV
SCIg
Synagis
Avastin
Gamma globulin, IM, over 10cc
Immune globulin-liquid 500mg
Immune globulin 100mg SQ
Immune globulin-powder 500mg
Immune globulin-liquid 500mg
Gamastan
Gamunex
Vivaglobulin
Orencia
Eylea
Fabrazyme
Lemtrada
J1569
J1572
J1575
J1599
Gammagard
Flebogamma
HyQvia
Alglucerase (per 10 units)
Alglucosidase Alfa, 10 mg
Alglucosidase Alfa, 10 mg
Alpha 1 proteinase inhibitor
10mg
Alpha 1 proteinase inhibitor
Belimumab, 10 mg
Onabotulinum toxin A
Abobotulinum toxin A
Ceredase
Myozyme
Lumizyme
Aralast, Prolastin,
Zemaira
Glassia
Benlysta
Botox
Dysport
J1602
J1744
J1745
J1786
Immune globulin-liquid 500 mg
Immune Globulin-liquid 500mg
Immune Globulin Infusion
Immune globulin-liquid 500mg,
NOS
Gloimumab
Icatibant
Inflizximab 10mg
Imiglucerase 10 units
Aldurazyme
Prialt
Rimabotulinum toxin B
Incobotulinumtoxin A
C1 esterase inhibitor
(recombinant)
C1 esterase inhibitor (human)
C1 esterase inhibitor (human)
Respoitory corticotropin
Darbepoetin alfa, non-ESRD 1
mcg
Darbepoetin alfa, ESRD 1 mcg
Myobloc
Xeomin
Ruconest
J2357
J2503
J2505
Laronidase 0.1mg
Ziconotide 1 mcg
Octreotide Acetate (depot form)
Octreotide Acetate (non-depot
form)
Omalizumab 5 mcg
Pegaptanib 0.3 mg
Pedfilgrastim 6 mg
Berinert
Cinryze
H.P. Acthar Gel
Aranesp
J2562
J2778
J2793
J2796
Plerixafor
Ranibizumab 0.1 mg
Rilonacept
Romiplostim
Mozobil
Lucentis
Arcalyst
Nplate
Aranesp
J2820
Sargramostim 50 mcg
J1931
J2278
J2353
J2354
Octagam
Simponi Aria
Firazyr
Remicade
Cerezyme
Xolair
Macugen
Neulasta
J2860
Siltuximab
Leukine,
Prokine
Sylvant
Epogen, Procrit
Mircera
J2940
Somatrem 1 mg
Protropin
Prolia/XGEVA
Kalbitor
Soliris
Flolan/Veletri
Neupogen
Granix
Naglazyme
Privigen
J2941
J3060
J3262
J3285
J3380
J3385
J7316
J7321
Somatropin 1 mg
Taliglucerase Alfa
Tocilizumab
Treprostinil Sodium
Vedolizumab
Velaglucerase alfa
Ocriplasmin
Hyaluronic acid (No review if Dx is
related to knee)
Hyaluronic acid (No review if Dx is
related to knee)
Hyaluronic acid (No review if Dx is
related to knee)
Hyaluronic acid (No review if Dx is
related to knee
Hyaluronic acid (No review if Dx is
related to knee)
Multiple
Elelyso
Actemra
Remodulin
Entyvio
VPRIV
Jetrea
Hyalgan,
Supartz
Euflexxa
J0897
J1290
J1300
J1325
J1442
J1447
J1458
J1459
Epoetin alfa, non-esrd 1000
units
Epoetin beta and methoxy
polyethylene glycol
Denosumab
Ecallantide
Eculizumab
Epoprostenol 0.5 mcg
Filgrastim
Tbo-filgrastim
Galsulfase 1 mg
Immune globulin-liquid 500mg
J1460
Gamma globulin, IM, 1cc
Gamastan
J7323
J1556
Immune globulin IV (human)
Bivigam
J7324
J1557
Immune globulin, liquid 500mg
Gammaplex
J7325
J1559
Immune globulin Subcutaneous
(Human)
Hizentra
J7326
J0887
GENERIC NAME
J1560
J1561
J1562
J1566
J1568
2
Orthovisc
Synvisc
Synvisc-One
Gel-One
UK-HMO Specialty Pharmacy Medical Management Drug List – Effective 7-1-2016 (cont.)
J7327
Monovisc
J9301
Obinutuzumab
Gazyva
Gel-Syn
J9302
Ofatumumab
Arzerra
Duopa
Tyvaso
Campath
Proleukin
Erwinaze
J9303
J9305
J9306
J9308
J9310
Panitumumab 10 mg
Pemetrexed 10 mg
Pertuzumab
Ramucirumab
Rituximab 10mg
Vectibix
Alimta
Perjeta
Cyramza
Rituxan
Elspar
Oncaspar
Avastin
J9351
J9354
J9355
Topotecan Hydrochloride
Ado-trastuzumab emtansine
Trastuzumab 10mg
Hycamtin
Kadcyla
Herceptin
J9039
J9042
J9043
J9047
Hyaluronic acid 88mg/4ml
syringe (No review if Dx is
related to knee)
Hyaluronic acid (No review if Dx
is related to knee)
Carbidopa and levodopa
Treprostinil
Alemtuzumab 10 mg
Aldesleukin
Asparaginase Erwinia
Chrysanthemi
Asparaginase
Pegaspargase
Bevacizumab 10mg (C9257 is
for
Blinatumomab
Brentuximab vedotin
Cabazitaxel
Carfilzomib
Blincyto
Adcetris
Jevtana
Kyprolis
J9400
Q2043
Q4074
Q4081
Folfiri
Sipuleucel-T
Iloprost inhalation
Epoetin alfa, DRSD (dialysis 100
J9055
J9179
Cetuximab 10 mc
Eribulin mesylate
Erbitux
Halaven
Q5101
Q9980
Filgrastim-sndz
Sodium hyaluronate (No review if
Dx is related to knee)
Zaltrap
Provenge
Ventavis
Epogen,
Procrit
Zarxio
GenVisc 850
J9228
J9264
Ipilmumab
Paclitaxel protein-bound
particles
Pembrolizumab
Nivolumab
Yervoy
Abraxane
J7328
J7340
J7686
J9010
J9015
J9019
J9020
J9020
J9035
J9271
J9299
Keytruda
Opdivo
3