4.5

Por 7mo año consecutivo somos calificados 4.5 Estrellas, de un total de 5, en calidad de cuidado de salud (2024 Contrato H4004)

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Políticas Médicas

Nuestras políticas médicas definen la manera en que MMM Holdings LLC y sus subsidiarias identifican y evalúan solicitudes de servicios específicos mediante la aplicación de guías clínicas. Las políticas se adhieren a las guías de Determinaciones de Cobertura Nacional y Local (NCD o LCD) y/o los Artículos definidos por los Centros de Medicare y Medicaid (CMS) y/o cualquier otro criterio clínico. Las políticas reflejan la investigación científica actual y los estándares de guías clínicas basadas en esta evidencia.

Políticas - Rx Parte B

Esta sección contiene los criterios clínicos para los medicamentos y terapias inyectables, en infusión o implantados cubiertos por el beneficio médico, que están sujetos a autorización previa. Los criterios clínicos se desarrollan para ayudar a guiar el uso clínicamente apropiado de medicamentos y terapias y son revisados y aprobados por el Comité de Farmacia y Terapéutica (P&T). El Comité de Farmacia y Terapéutica es un comité independiente y externo que incluye médicos practicantes, farmacéuticos y clínicos de los principales centros médicos académicos y prácticas clínicas con experiencia en medicina basada en la evidencia.

Brand Name Generic Name HCPCS Code Policy Name Policy Number
Abraxane Paclitaxel J9264 Paclitaxel, Protein Bound (Abraxane®) MP-RX-FP-69-23
Abrilada Adalimumab-afzb J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Actemra Tocilizumab J3262 Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) MP-RX-FP-59-23
Adcetris Brentuximab J9042 Brentuximab vedotin (Adcetris®) MP-RX-FP-01-23
Advate Antihemophilic Factor (Rcmb) Plasma/Albumin Free (rAHF-PFM) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Adynovate  Antihemophilic Factor (Recombinant) Pegylated J7207 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Afstyla Antihemophilic Factor (Recombinant) Single Chain J7210 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Aimovig Erenumab C9399; J3490; J3590 CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) MP-RX-FP-17-23
Ajovy Fremanezumab-vfrm J3031 CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) MP-RX-FP-17-23
Akynzeo Netupitant, palonosetron J8655 Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) LCD: L33827 - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
Alimta Pemetrexed J9305 Pemetrexed (Alimta®, Pemfexy®) MP-RX-FP-05-23
Alphanate  Antihemophilic viii/vwf comp J7186 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
AlphaNine Coagulation Factor IX J7193 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Alprolix Coagulation Factor IX (Recomb) Fc Fusion Protein (rFIXFc) J7201 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Altuviio Factor VIII/von Willebrand factor complex, recombinant J7214 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Amjevita Adalimumab-atto J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Aralast Alpha1-Proteinase Inhibitor (Human) J0256 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Aranesp (Albumin Free) Darbepoetin alfa, non-esrd J0881 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Aranesp (Albumin Free) Darbepoetin alfa, esrd use J0882 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Atgam Lymphocyte Immune Globulin,Anti-Thymocyte Globulin (Equine) J7504 Antithymocyte Globulin Equine, (Atgam) MP-RX-FP-08-24
Avastin Bevacizumab J9035 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) MP-RX-FP-13-23
Avsola Infliximab-axxq Q5121 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Bavencio Avelumab J9023 Avelumab (Bavencio®) MP-RX-FP-09-23
Belrapzo Bendamustine J9036 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
Bendeka Bendamustine J9034, J9058, J9059 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
BeneFix Coagulation Factor IX (Recombinant) J7195 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Benlysta Belimumab J0490 Benlysta (belimumab) MP-RX-FP-11-23
Beovu Brolucizumab-dbll J0179 Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] MP-RX-FP-100-23
Berinert C1 Esterase Inhibitor (Human) J0597 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Besponsa Inotuzumab J9229 Inotuzumab ozogamicin (Besponsa®) MP-RX-FP-12-23
Blincyto Blinatumomab J9039 Blinatumomab (Blyncito®) MP-RX-FP-14-23
Bonsity Teriparatide J3110 Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) MP-RX-FP-37-23
Botox OnabotulinumtoxinA J0585 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Cabenuva Cabotegravir & Rilpivirine J0741 Cabotegravir extended-release; rilpivirine extended-release (Cabenuva) MP-RX-FP-16-23
Cerezyme Imiglucerase J1786 Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) MP-RX-FP-29-23
Cimzia Certolizumab pegol J0717 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Cinqair Reslizumab J2786 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Cinryze C1 Esterase Inhibitor (Human) J0598 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Coagadex Coagulation Factor X (Human) J7175 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Corifact Factor XIII Concentrate (Human) J7180 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Cosentyx Secukinumab C9399; J3490; J3590 Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] MP-RX-FP-60-23
Cyltezo Adalimumab-adbm J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Cyramza Ramucirumab J9308 Ramucirumab (Cyramza®) MP-RX-FP-20-23
Darzalex Daratumumab J9145 Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) MP-RX-FP-21-23
Darzalex Faspro Daratumumab and hyaluronidase-fijh J9144 Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) MP-RX-FP-21-23
Duopa Carbidopa-Levodopa J7340 Carbidopa and levodopa enteral suspension (Duopa) MP-RX-FP-22-23
Dupixent Dupilumab C9399; J3490; J3590 Dupilumab (Dupixent) MP-RX-FP-23-23
Durolane Sodium Hyaluronate (Viscosupplement) J7318 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Durysta Bimatoprost J7351 Durysta [Bimatoprost Implant] MP-RX-FP-24-23
Dysport AbobotulinumtoxinA J0586 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Egrifta Tesamorelin Acetate J3490; J3590 Tesamorelin (Egrifta) MP-RX-FP-25-23
Elelyso Taliglucerase Alfa J3060 Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) MP-RX-FP-29-23
Eligard Leuprolide J9217 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Eloctate Antihemophilic Factor (Recombinant) Fc Fusion Protein(BDD-rFVIIIFc) J7205 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Emend Aprepitant, oral J8501 Oral antiemetic drugs: Aprepitant MP-RX-FP-07-23
Emgality Galcanezumab C9399; J3490; J3590 CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) MP-RX-FP-17-23
Empliciti Elotuzumab J9176 Elotuzumab (Empliciti®) MP-RX-FP-26-23
Enbrel Etanercept J1438 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Enhertu fam-trastuzumab deruxtecan-nxk J9358 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Entyvio Vedolizumab J3380 Vedolizumab (Entyvio) MP-RX-FP-28-23
Epogen Epoetin alfa, esrd Q4081 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Epogen Epoetin alfa, non-esrd J0885 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Erbitux Cetuximab J9055 Cetuximab (Erbitux®) MP-RX-FP-30-23
Erelzi Etanercept-szzs J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Esperoct  Antihemophilic Factor (Recombinant) Glycopegylated-exei J7204 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Eticovo Etanercept-ykro J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Euflexxa Sodium Hyaluronate (Viscosupplement) J7323 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Evenity Romosozumab-aqqg J3111 Romosozumab (Evenity) MP-RX-FP-32-23
Eylea Aflibercept J0178 Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] MP-RX-FP-100-23
Fasenra Benralizumab J0517 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Fasenra Pen Benralizumab J0517 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Feiba NF Antiinhibitor Coagulant Complex J7198 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Fensolvi Leuprolide J1951 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Feraheme Ferumoxytol Q0138 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Ferrlecit Sodium ferric gluconate/sucrose complex J2916 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Fibryga Fibrinogen Concentrate (Human) J7177 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Firazyr Icatibant Acetate J1744 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Firmagon Firmagon J9155 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Firmagon (240 MG Dose) Degarelix J9155 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Forteo Teriparatide (Recombinant) J3110 Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) MP-RX-FP-37-23
Fulphila Pegfilgrastim-jmdb Q5108 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Gammagard Gammagard liquid injection J1569 Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] MP-RX-FP-40-23
Gammagard S/D Immune Globulin (Human) IV J1566 Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] MP-RX-FP-40-23
Gamunex Immune Globulin (Human) IV J1561 Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] MP-RX-FP-40-23
Gazyva Obinutuzumab J9301 Obinutuzumab (Gazyva®) MP-RX-FP-33-23
Gel-One Cross-Linked Hyaluronate J7326 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Gel-Syn Hyaluronan or derivative, for intra-articular injection J7328 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
GenVisc 850 Sodium Hyaluronate (Viscosupplement) J7320 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Glassia Alpha1-Proteinase Inhibitor (Human) J0257 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Granix Tbo-Filgrastim J1447 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Hadlima Adalimumab-bwwd J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Haegarda C1 Esterase Inhibitor (Human) J0599 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Halaven Eribulin J9179 Eribulin mesylate (Halaven®) MP-RX-FP-35-23
Hemlibra  Emicizumab-kxwh J7170 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Hemofil-M Antihemophilic Factor (Human) J7190 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Herceptin Trastuzumab J9355 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Herceptin Hylecta Trastuzumab, and hyaluronidase-oysk J9356 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Herzuma Trastuzumab-pkrb Q5113 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Hulio Adalimumab-fkjp J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Humalog®, Humulin®, Novolin®, Novolog®, Insulin Lispro®, Apidra Solostar® Insulin Lispro or Aspart for insulin pump use J1817, S5550, S5551 Infusion Pumps NCD: 280.14 - Infusion Pumps
Humate-P Antihemophilic Factor/von Willebrand Factor Complex (Human) J7187 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Humira Adalimumab J0135 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Hyalgan Sodium Hyaluronate (Viscosupplement) J7321 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Hymovis Hyaluronan J7322 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Hyqvia Immune Globulin (Human)-Hyaluronidase (Human Recombinant) J1575 Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] MP-RX-FP-40-23
Hyrimoz Adalimumab-adaz J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Idacio Adalimumab-aacf J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Idelvion Coagulation Factor IX Recomb Albumin Fusion Protein (rIX-FP) J7202 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Ilumya Tildrakizumab-asmn J3245 Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] MP-RX-FP-61-23
Iluvien Fluocinolone acetonide intravitreal implant J7313 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
Imfinzi Durvalumab J9173 Durvalumab (Imfinzi®) MP-RX-FP-39-23
Infed Iron dextran J1750 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Inflectra Infliximab-dyyb Q5103 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Infliximab Infliximab J1745 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Injectafer Ferric carboxymaltose J1439 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
ISTODAX Romidepsin J9319 Romidepsin (Istodax®) MP-RX-FP-45-23
IXEMPRA Ixabepilone J9207 Ixabepilone (Ixempra®) MP-RX-FP-46-23
Ixifi Infliximab-qbtx Q5109 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Ixinity Coagulation Factor IX (Recombinant) J7195 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Jevtana Cabazitaxel J9043, J9064 Cabazitaxel (Jevtana®) MP-RX-FP-47-23
Jivi Antihemophilic Factor (Recombinant) PEGylated-aucl (BDD-rFVIII PEG-aucl) J7208 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Kadcyla ado-trastuzumab emtansine J9354 Ado-trastuzumab (Kadcyla®) MP-RX-FP-48-23
Kalbitor Ecallantide J1290 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Kanjinti Trastuzumab Q5117 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Kevzara Sarilumab C9399; J3490; J3590 Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) MP-RX-FP-59-23
Keytruda Pembrolizumab J9271 Pembrolizumab (Keytruda®) MP-RX-FP-49-23
Koate Antihemophilic Factor (Human) J7190 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Kogenate FS Antihemophilic Factor (Recombinant) (rFVIII) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Kovaltry Antihemophilic Factor (Recombinant) Plasma/Albumin Free (rAHF-PFM) J7211 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Krystexxa Pegloticase J2507 Krystexxa (pegloticase) MP-RX-FP-50-23
Kyprolis Carfilzomib J9047 Carfilzomib (Kyprolis®) MP-RX-FP-51-23
Lanreotide Lanreotide (cipla) J1932 Lanreotide (Somatuline Depot) MP-RX-FP-83-23
Lemtrada Alemtuzumab J0202 Alemtuzumab [Lemtrada] MP-RX-FP-52-23
Leqvio Inclisiran, 1 mg J1306 Inclisiran [Leqvio] MP-RX-FP-53-23
Libtayo cemiplimab-rwlc J9119 Cemiplimab-rwlc (Libtayo®) MP-RX-FP-54-23
Lucentis Ranibizumab J2778 Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] MP-RX-FP-100-23
Lunsumio mosunetuzumab-axgb J9350 Mosunetuzumab-axgb (Lunsumio®) MP-RX-FP-55-23
Lupaneta Leuprolide J1950 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Lupron Depot (1-Month) Leuprolide J1950 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Lupron Depot (3-Month) Leuprolide J9217 (Non-Oncology), J1950 (Oncology) GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Lupron Depot (6-Month) Leuprolide J9217 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Margenza Margetuximab J9353 Margetuximab-cmkb (Margenza®) MP-RX-FP-56-23
Monjuvi Tafasitamab J9349 Tafasitamab-cxix (Monjuvi®) MP-RX-FP-57-23
Monoferric Ferric derisomaltose J1437 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Monovisc Hyaluronan J7327 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Mvasi Bevacizumab Q5107 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) MP-RX-FP-13-23
MYCOPHENOLATE MOFETIL ORAL Mycophenolate mofetil J7517 Immunosuppressive Drugs A52474 - Immunosuppressive Drugs - Policy Article
MYCOPHENOLATE SODIUM Mycophenolic acid J7518 Immunosuppressive Drugs A52474 - Immunosuppressive Drugs - Policy Article
Mylotarg gemtuzumab ozogamicin J9203 Gemtuzumab ozogamicin (Mylotarg®) MP-RX-FP-62-23
Myobloc RimabotulinumtoxinB J0587 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Neulasta Pegfilgrastim J2506 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Neupogen Filgrastim J1442 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Nivestym Filgrastim-aafi Q5110 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Novoeight  Antihemophilic Factor VIII (Recombinant) BD Truncated (BD trunc-rFVIII) J7182 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
NovoSeven RT Coagulation Factor VIIa (Recombinant) J7189 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Nplate Romiplostim J2796 Romiplostim (Nplate) MP-RX-FP-63-23
Nucala Mepolizumab J2182 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Nuwiq Antihemophilic Factor (Rcmb) Simoctocog alfa(BDD-rFVIII,sim) J7209 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Nyvepria Pegfilgrastim-apgf Q5122 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Obizur Antihemophilic Factor (Recombinant Porcine) (rpFVIII) J7188 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Ocrevus Ocrelizumab J2350 Ocrelizumab [Ocrevus] MP-RX-FP-64-23
OGIVRI Trastuzumab-dkst Q5114 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Ontruzant trastuzumab-dttb Q5112 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Opdivo Nivolumab J9299 Nivolumab (Opdivo®) MP-RX-FP-66-23
OPDUALAG nivolumab and relatlimab-rmbw J9298 Nivolumab and relatlimab-rmbw (Opdualag®) MP-RX-FP-67-23
Orencia Abatacept J0129 Orencia (abatacept) MP-RX-FP-68-23
Orladeyo Berotralstat HCl J8499 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Orthovisc Hyaluronan J7324 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Ozurdex Dexamethasone intravitreal implant J7312 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
PACLitaxel Protein-Bound Part Paclitaxel J9264 Paclitaxel, Protein Bound (Abraxane®) MP-RX-FP-69-23
Padcev Enfortumab J9177 Enfortumab vedotin-ejfv (Padcev®) MP-RX-FP-70-23
Panzyga  Ivig non-lyophilized, nos J1599 Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] MP-RX-FP-40-23
PEMETREXED Pemetrexed J9314, J9322, J9323, J9294, J9296, J9297 Pemetrexed (Alimta®, Pemfexy®) MP-RX-FP-05-23
Pemfexy Pemetrexed J9304 Pemetrexed (Alimta®, Pemfexy®) MP-RX-FP-05-23
Perjeta Pertuzumab J9306 Pertuzumab (Perjeta®) MP-RX-FP-71-23
Phesgo pertuzumab, trastuzumab, and hyaluronidase-zzxf, J9316 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Polivy Polatuzumab J9309 Polatuzumab vedotin-piiq (Polivy®) MP-RX-FP-73-23
Privigen  Inj ivig privigen 500 mg J1459 Immunoglobulins [Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify] MP-RX-FP-40-23
Procrit Epoetin alfa, non-esrd J0885 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Procrit Epoetin alfa, 100 units esrd Q4081 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Profilnine Factor IX Complex J7194 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Prolastin Alpha1-Proteinase Inhibitor (Human) J0256 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Radicava Edaravone J1301 Radicava (edaravone) MP-RX-FP-75-23
Rebinyn Coagulation Factor IX (Recombinant) Glycopegylated J7203 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Reblozyl Luspatercept-aamt J0896 Luspatercept (Reblozyl) MP-RX-FP-76-23
Recombinate Antihemophilic Factor (Recombinant) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Remicade Infliximab J1745 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Renflexis Infliximab-abda Q5104 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Retacrit Inj retacrit esrd on dialysi Q5105 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Retisert Fluocinolone acetonide intravitreal implant J7311 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
Riabni Rituximab Q5123 Rituximab Agents for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23 
RiaSTAP Fibrinogen Concentrate (Human) J7178 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Rituxan Rituximab J9312 Rituximab Agents for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23 
Rixubis Coagulation Factor IX (Recombinant) J7200 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Rolvedon Eflapegrastim-xnst J1449 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Ruconest C1 Esterase Inhibitor (Recombinant) J0596 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Ruxience Rituximab Q5119 Rituximab Agents for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23 
Rybrevant amivantamab-vmjw J9061 Amivantamab-vmjw (Rybrevant®) MP-RX-FP-79-23
Sajazir Icatibant Acetate J1744 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
SandoSTATIN Octreotide injection, non-depot J2354 Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) MP-RX-FP-65-23
SandoSTATIN LAR Depot Octreotide injection, depot J2353 Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) MP-RX-FP-65-23
Saphnelo Anifrolumab-fnia J0491 Saphnelo (anifrolumab-fnia) MP-RX-FP-80-23
Sarclisa Isatuximab J9227 isatuximab (Sarclisa®) MP-RX-FP-81-23
SevenFact Coagulation Factor VIIa (Recombinant)-jncw J7212 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Siliq brodalumab C9399; J3490; J3590 Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] MP-RX-FP-60-23
Simponi Golimumab J1602 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Simponi Aria Golimumab J1602 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Skyrizi IV Risankizumab-rzaa J2327 Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] MP-RX-FP-61-23
Soliris Eculizumab J1300 Complement Inhibitors: Soliris [eculizumab], Ultomiris [ravulizumab-cwvz] MP-RX-FP-19-23
Somatuline Depot Lanreotide Acetate J1930 Lanreotide (Somatuline Depot) MP-RX-FP-83-23
Spinraza Nusinersen J2326 Spinraza (nusinersen) MP-RX-FP-84-23
Stelara IV Ustekinumab, iv inject, 1 mg J3358 Stelara (ustekinumab) MP-RX-FP-85-23
Stelara SQ Ustekinumab sub cu inj, 1 mg J3357 Stelara (ustekinumab) MP-RX-FP-85-23
Supprelin Leuprolide J9217 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Syfovre Pegcetacoplan J2781 Syfovre (pegcetacoplan) MP-RX-FP-86-23
Sylvant Siltuximab J2860 Sylvant (siltuximab) MP-RX-FP-87-23
Synojoynt Sodium Hyaluronate (Viscosupplement) J7331 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Synvisc Hylan J7325 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Synvisc-One Hylan J7325 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
TACROLIMUS IMME REL ORAL 1MG Tacrolimus immediate release J7507 Immunosuppressive Drugs A52474 - Immunosuppressive Drugs - Policy Article
Takhzyro Lanadelumab-flyo J0593 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Taltz Ixekizumab C9399; J3490; J3590 Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] MP-RX-FP-60-23
Tecentriq Atezolizumab J9022 Atezolizumab (Tecentriq) MP-RX-FP-88-23
Tepezza Teprotumumab-trbw J3241 Teprotumumab-trbw (Tepezza) MP-RX-FP-89-23
Tezspire Tezepelumab-ekko J2356 Tezepelumab-ekko (Tezspire) MP-RX-FP-90-23
Torisel Temsirolimus J9330 Temsirolimus (Torisel®) MP-RX-FP-91-23
Trazimera Trastuzumab-qyyp Q5116 Trastuzumab – Trastuzumab Biologics LCD: L34026 - Trastuzumab – Trastuzumab Biologics
Treanda Bendamustine J9033 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
TRELSTAR Triptorelin J3315 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Tremfya Guselkumab J1628 Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] MP-RX-FP-61-23
Triesence Triamcinolone acetonide preservative-free J3300 Triamcinolone acetonide injectable suspensión [Xipere, Triesence] MP-RX-FP-93-23
Triferic Ferric pyrophosphate citrate J1443 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Triferic AVNU Ferric pyrophosphate citrate J1445 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Triluron Sodium Hyaluronate (Viscosupplement) J7332 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Trivisc Sodium Hyaluronate (Viscosupplement) J7329 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Trodelvy Sacituzumab J9317 Sacituzumab govitecan (Trodelvy®) MP-RX-FP-94-23
Trogarzo Ibalizumab-uiyk J1746 Ibalizumab-uiyk (Trogarzo) MP-RX-FP-95-23
Truxima Rituximab Q5115 Rituximab Agents for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23 
Tymlos Abaloparatide C9399; J3490; J3590 Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) MP-RX-FP-37-23
Tysabri Natalizumab J2323 Natalizumab (Tysabri) MP-RX-FP-97-23
Udenyca Pegfilgrastim-cbqv Q5111 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Ultomiris Ravulizumab-cwvz J1303 Complement Inhibitors: Soliris [eculizumab], Ultomiris [ravulizumab-cwvz] MP-RX-FP-19-23
Uplizna Inebilizumab-cdon J1823 Uplizna (inebilizumab-cdon) MP-RX-FP-98-23
Vabysmo Faricimab-svoa J2777 Vascular Endothelial Growth Factor (VEGF) Inhibitors: [Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumabawwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa)] MP-RX-FP-100-23
Vectibix Panitumumab J9303 Panitumumab (Vectibix®) MP-RX-FP-99-23
Venofer Iron sucrose J1756 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Vimizim Elosulfase Alfa J1322 Vimizim (elosulfase alfa) MP-RX-FP-102-23
Visudyne Verteporfin J3396 Verteporfin [Visudyne] MP-RX-FP-101-23
Vivimusta Bendamustine J9056 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
Vonvendi  Von Willebrand Factor (Recombinant) J7179 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Vpriv Velaglucerase Alfa J3385 Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) MP-RX-FP-29-23
Vyepti Eptinezumab-jjmr J3032 Eptinezumab-jjmr (Vyepti) MP-RX-FP-103-23
Wilate Antihemophilic Factor/von Willebrand Factor Complex (Human) J7183 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Xeomin IncobotulinumtoxinA J0588 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Xiaflex Collagenase Clostridium Histolyticum J0775 Xiaflex (collagenase clostridium histolyticum) injection MP-RX-FP-104-23
Xipere Triamcinolone acetonide J3301 Triamcinolone acetonide injectable suspension [Xipere, Triesence] MP-RX-FP-93-23
Xolair Omalizumab J2357 Omalizumab [Xolair] MP-RX-FP-105-23
Xyntha Solofuse Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Xyntha  Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) J7185 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Yervoy Ipilimumab J9228 Ipilimumab (Yervoy®) MP-RX-FP-106-23
Yuflyma Adalimumab-aaty J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Yusimry Adalimumab-aqvh J3490, J3590 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Yutiq Fluocinolone acetonide intravitreal implant J7314 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
Zaltrap Aflibercept J9400 Ziv-aflibercept (Zaltrap®) MP-RX-FP-107-23
Zarxio Filgrastim-sndz Q5101 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Zemaira Alpha1-Proteinase Inhibitor (Human) J0256 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Zepzelca Lurbinectedin J9223 Lurbinectedin (Zepzelca®) MP-RX-FP-108-23
Ziextenzo Pegfilgrastim-bmez Q5120 Colony Stimulating Factors: [Elfapegrastim agents (Rolvedon). Filgrastim agents (Neupogen, Nivestym, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo). Sargramostim agents (Leukine, Prokine)] MP-RX-FP-18-23
Zinplava  Bezlotoxumab J0565 Bezlotoxumab (Zinplava) MP-RX-FP-109-23
Zirabev Bevacizumab Q5118 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) MP-RX-FP-13-23
Zoladex Goserelin J9202 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Zynlonta loncastuximab tesirine-lpyl J9359 Loncastuximab tesirine-lpyl (Zynlonta®) MP-RX-FP-110-23
Abecma Idecabtagene vicleucel Q2055 Idecabtagene vicleucel (Abecma®) MP-RX-FP-111-23
Breyanzi Lisocabtagene maraleucel Q2054 Lisocabtagene maraleucel (Breyanzi®) MP-RX-FP-112-23
Carvykti Ciltacabtagene autoleucel Q2056 Ciltacabtagene autoleucel (Carvykti®) MP-RX-FP-113-23
Kymriah Tisagenlecleucel Q2042 Tisagenlecleucel (Kymriah®) MP-RX-FP-114-23
Tecartus Brexucabtagene autoleucel Q2053 Brexucabtagene autoleucel (Tecartus®) MP-RX-FP-115-23
Yescarta axicabtagene ciloleucel Q2041 Axicabtagene ciloleucel (Yescarta®) MP-RX-FP-116-23

Políticas de Manejo de Utilización Clínica

Las Políticas de Utilización Médica definen la manera en que MMM Holdings LLC y sus subsidiarias identifican y evalúan solicitudes de servicios específicos y facilitan un proceso de determinación consistente de acuerdo con las regulaciones de los Centros de Medicare y Medicaid (CMS).

Medical Policy Title Medical Policy Number
Capsule Opacification Following Cataract Surgery MP-SU-FP-01-23
Ankle-Foot/Knee-Ankle-Foot Orthoses MP-HO-FP-01-23
Knee Orthoses MP-HO-FP-02-23
Cervical Traction Devices MP-HO-FP-03-23
External Breast Prostheses MP-HO-FP-04-23
Orthopedic Footwear MP-HO-FP-05-23
Pneumatic Compression Devices MP-HO-FP-06-23
Therapeutic Shoes for Persons with Diabetes MP-HO-FP-07-23
Lower Limb Prostheses MP-HO-FP-08-23
Spinal Orthoses: TLSO and LSO MP-HO-FP-09-23
Surgical Dressings MP-HO-FP-10-23
External Breast Prostheses MP-HO-FP-11-23
Knee Orthoses MP-HO-FP-12-23
Therapeutic Shoes for Persons with Diabetes MP-HO-FP-13-23
Orthopedic Footwear MP-HO-FP-14-23
Ankle-Foot/Knee-Ankle-Foot Orthosis MP-HO-FP-15-23
Lower Limb Prostheses MP-HO-FP-16-23
Spinal Orthoses: TLSO and LSO MP-HO-FP-17-23
Cervical Traction Devices MP-HO-FP-18-23
Pneumatic Compression Devices MP-HO-FP-19-23
Surgical Dressings MP-HO-FP-20-23
Sub-Acute Levels of Care (Skill Nursing and Rehab) MP-HSIP-005-FP-01-23
Evaluation and Determination of Pre-Authorization Services MP-HSOP-013-FP-01-23
Transportation Process for Non-Emergency Ambulance Services (NEA) MP-HSTU-01-FP-01-23
Abdominal Lipectomy/Panniculectomy MP-SU-FP-02-23
Bariatric Surgery MP-SU-FP-03-23
Stem Cell Transplantation Autologous/Allogenic MP-SCT-FP-03-23
Refractive Keratoplasty/Cornea Transplant MP-CT-FP-05-23
Heart/Lung Transplant MP-HLT-FP-08-23 
Heart Transplants MP-HT-FP-01-23
Hyperbaric Oxygen Therapy MP-HOT-FP-02-23
Intestine and Multi-Visceral Transplantation MP-IT-FP-06-23
IV Antibiotics/Hydration Administration (IV)/External Infusion Pumps MP-IV-FP-01-23
Kidney Transplant MP-KT-FP-09-23
Adult Liver Transplantation MP-LT-FP-02-23
Lung Transplant MP-LT-FP-07-23
Pancreas Transplant MP-PT-FP-04-23
Skin Substitute Grafts MP-SSG-FP-03-23
Wound Care (Debridements, Wound Negative Pressure Therapy (Vac Therapy), Surgical Dressings) MP-WC-FP-01-23 
Wound Electrical Stimulation and Electromagnetic Therapy MP-WES-FP-04-23 
Occupational, Speech and Physical Therapy Guidelines Occupational, Speech and Physical Therapy Guidelines
Psychiatric Diagnostic Evaluation and Psychotherapy Services MP-EM-DP-02-23
Neuropsychological Tests MP-EM-DP-03-23
2024 Pre Authorization Medicare Advantage - CMS Clinical Guidelines Crosswalk 11-2023 CMS Clinical Guidelines Crosswalk
GMT Medicare Crosswalk 2024 GMT Medicare Crosswalk 2024
Molecular Testing Review Criteria Molecular Testing Review Criteria
Additional information available – please contact: liz.roman@mso-pr.com and or sindia.Villegas@mso-pr.com
Imaging Services - MCG private license-guidelines can be provided per request liz.roman@mso-pr.com and or sindia.Villegas@mso-pr.com