Prior authorization request form Form

Questions? Please call the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4510 www.alamedaalliance.org UMUM MED AUTH UPDATE06/2023 FAXED: XX/XX/XXXX Important Update: Utilization Management (UM) Medication (Physician or Facility- Administered Medications/Injections in All Settings) That Require Authorization

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have an important update we would like to share with you.
Our provider partner satisfaction is a top priority. We are working to improve our Utilization Management and Claims processes to help ensure proper claim payment to our provider partners, and alignment of authorized services. To accomplish this goal, we are reviewing each benefit and we will be sending you updates, as the information is ready to share.
This communication provides an update on Utilization Management (UM) Medications (including physician or facility-administered medications/injections in all settings) codes that require prior authorization. This does not include outpatient pharmacy services through the member’s pharmacy benefit. This will affect claims with the date(s) of service starting Friday, September 1, 2023, and onward. Enclosed with this notice is a code-specific list that shows which codes require PA. This list is also available on the Alliance website at www.alamedaalliance.org/providers/authorizations. Please refer to our website for the most up-to-date information about codes or benefits that require authorization.
Please note, for service codes that do not require prior authorization but are associated with a prior authorization required service, there must be an approved authorization on file for the primary service requiring authorization in order for the associated code(s) to be paid. Associated codes not on the prior authorization list will not be paid separately if the primary service was denied or does not have prior authorization. In addition to the codes, our claims system will also validate that the claim received matches the authorization when authorization is required.
The following items will be validated: • Member name
• Provider NPI • CPT and HCPC coding
• Date(s) of service is within the authorized range • Number of units and/or visits
• Place of service matches site of care submitted on the authorization request form
• National Drug Codes (NDCs) approved by the FDA are required on claims submissions
• Claims missing and/or without a matching NDC on a claim will be denied This update has been validated based on current and published billable coding for (enter year) and was confirmed to be covered by the California Department of Health Care Services (DHCS). Thank you for your continued partnership and for providing high-quality care to our members and the community.

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO A9513 LUTETIUM LU 177 DOTATATE Alameda Alliance for Health or Delegate A9543 IBRITUMOMAB TIUXETAN Alameda Alliance for Health or Delegate A9604 SAMARIUM SM-153 LEXIDRONAM Alameda Alliance for Health or Delegate A9606 RADIUM RA 223 DICHLORIDE Alameda Alliance for Health or Delegate J0129 ORENCIA (ABATACEPT) 10 MG Alameda Alliance for Health or Delegate J0135 HUMIRA (ADALIMUMAB) 20MG Alameda Alliance for Health or Delegate J0178 EYLEA (AFLIBERCEPT) 1 MG Alameda Alliance for Health or Delegate J0180 FABRAZYME (AGALSIDASE BETA) 1 MG Alameda Alliance for Health or Delegate J0185 APREPITANT, 1MG
Alameda Alliance for Health or Delegate J0220 MYOZYME (ALGLUCOSIDASE ALFA) 10 MG Alameda Alliance for Health or Delegate J0221 LUMIZYME INJECTION (ALGLUCOSIDASE ALFA) 10 MG Alameda Alliance for Health or Delegate J0256 PROLASTIN (ALPHA 1 PROTEINASE INBITOR) 10 MG Alameda Alliance for Health or Delegate J0257 GLASSIA (ALPHA 1 PROTEINASE INBITOR) 10 MG Alameda Alliance for Health or Delegate J0480 SIMULECT (BASILIXIMAB) 10 MG Alameda Alliance for Health or Delegate J0485 NULOJIX (BELATACEPT) 1 MG Alameda Alliance for Health or Delegate J0585 BOTOX (ONABOTULINUMTOXINA), PER 1 UNIT Alameda Alliance for Health or Delegate J0586 DYSPORT (ABOBOTULINUMTOXINA) 5 UNITS Alameda Alliance for Health or Delegate J0587 MYOBLOC (RIMABOTULINUMTOXINB), BOTULINUM TOXIN TYPE B, PER 100 UNITS Alameda Alliance for Health or Delegate J0588 XEOMIN (INCOBOTULINUMTOXIN A) 1 UNIT Alameda Alliance for Health or Delegate J0597 BERINERT (C-1 ESTERASE) 10 UNITS Alameda Alliance for Health or Delegate J0598 CINRYZE (C-1 ESTERASE) 10 UNITS Alameda Alliance for Health or Delegate J0638 ILARIS (CANAKINUMAB) 1 MG Alameda Alliance for Health or Delegate Before services are provided, please check: Member Eligibility ▪ Medical Group ▪ Benefit Coverage ▪ Contracted Provider ▪ Medi-Cal Excluded Code Questions? Please call the Alliance Provider Services Department at 1.510.747.4510 Alameda Alliance for Health Referral and Prior Authorization (PA) Procedure Codes Utilization Management (UM) Medications UM Medications Please note: This list does not include all services. Page 1 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J0641 LEVOLEUCOVORIN 0.5 MG Alameda Alliance for Health or Delegate J0717 CERTOLIZUMAB PEGOL 1MG Alameda Alliance for Health or Delegate J0800 INJECTION CORTICOTROPIN UP 40 UNITS (Alliance Group Care only; not covered by Medi-Cal) Alameda Alliance for Health or Delegate J0881 ARANESP (DARBEPOETIN ALFA, NON-ESRD) 1 MCG Alameda Alliance for Health or Delegate J0882 DARBEPOETIN ALFA, ESRD USE 1 MCG Alameda Alliance for Health or Delegate J0885 EPOETIN ALFA, NON-ESRD 1000 UNITS Alameda Alliance for Health or Delegate J0887 MIRCERA (EPOETIN BETA) ESRD USE 1 MCG Alameda Alliance for Health or Delegate J0894 DECITABINE INJECTION 1 MG
Alameda Alliance for Health or Delegate J0897 PROLIA (DENOSUMAB) 1 MG Alameda Alliance for Health or Delegate J1300 SOLIRIS (ECULIZUMAB) 10 MG Alameda Alliance for Health or Delegate J1303 RAVULIZUMAB-CWVZ 10 MG Alameda Alliance for Health or Delegate J1325 INJECTION EPOPROSTENOL 0.5 MG Alameda Alliance for Health or Delegate J1439 FERRIC CARBOXYMALTOS 1MG Alameda Alliance for Health or Delegate J1442 FILGRASTIM G-CSF 1MCG Alameda Alliance for Health or Delegate J1447 TBO FILGRASTIM (GRANIX) BIOSIMILAR 1 MCG Alameda Alliance for Health or Delegate J1454 FOSNETUPITANT, PALONOSET
Alameda Alliance for Health or Delegate J1456 FOSAPREPITANT 1.65 MG Alameda Alliance for Health or Delegate J1458 NAGLAZYME (GALSULFASE) 1 MG Alameda Alliance for Health or Delegate J1459 IMMUNE GLOBULIN PRIVIGEN 500 MG Alameda Alliance for Health or Delegate J1460 GAMMA GLOBULIN 1 ML Alameda Alliance for Health or Delegate J1555 IMMUNE GLOBULIN CUVITRU 100 MG Alameda Alliance for Health or Delegate J1556 IMMUNE GLOBULIN GLOB BIVIGAM 500MG Alameda Alliance for Health or Delegate J1557 GAMMAPLEX (IMMUNE GLOBULIN) 500 MG Alameda Alliance for Health or Delegate J1559 HIZENTRA (IMMUNE GLOBULIN) 100 MG Alameda Alliance for Health or Delegate J1560 GAMMA GLOBULIN 10 ML Alameda Alliance for Health or Delegate J1561 GAMUNEX INJECTION, GAMUNEX-C/GAMMAKED (IMMUNE GLOBULIN) 500 MG Alameda Alliance for Health or Delegate J1562 VIVAGLOBIN (IMMUNE GLOBULIN) 100 MG Alameda Alliance for Health or Delegate J1566 IMMUNE GLOBULIN, POWDER 500 MG Alameda Alliance for Health or Delegate J1568 OCTAGAM (IMMUNE GLOBULIN) 500 MG Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 2 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J1569 GAMMAGARD LIQUID (IMMUNE GLOBULIN) 500 MG Alameda Alliance for Health or Delegate J1571 HEPAGAM B Alameda Alliance for Health or Delegate J1572 FLEBOGAMMA (IMMUNE GLOBULIN) Alameda Alliance for Health or Delegate J1575 HYQVIA 100MG IMMUNEGLOBULIN 100 MG Alameda Alliance for Health or Delegate J1599 IVIG NON-LYOPHILIZED, NOS IMMUNE GLOBULIN Alameda Alliance for Health or Delegate J1675 INJ HISTRELIN ACTAT 10 MICROGMS Alameda Alliance for Health or Delegate J1726 MAKENA, 10 MG Alameda Alliance for Health or Delegate J1743 ELAPRASE (IDURSULFASE) 1 MG Alameda Alliance for Health or Delegate J1745 REMICADE (INFLIXIMAB) EXCLUDE BIOSIMILAR 10 MG Alameda Alliance for Health or Delegate J1786 CEREZYME (IMIGLUCERASE) 10 UNITS Alameda Alliance for Health or Delegate J1826 INTERFERON BETA-1A INJ REBIF OR AVONEX 30 MCG Alameda Alliance for Health or Delegate J1930 SOMATULINE DEPOT (LANREOTIDE) 1 MG Alameda Alliance for Health or Delegate J1931 ALDURAZYME (LARONIDASE) 0.1MG Alameda Alliance for Health or Delegate J1950 LEUPROLIDE ACETATE PER 3. 75 MG Alameda Alliance for Health or Delegate J2323 NATALIZUMAB 1 MG Alameda Alliance for Health or Delegate J2350 OCRELIZUMAB, 1MG Alameda Alliance for Health or Delegate J2353 SANDOSTATIN (OCTREOTIDE, DEPOT) 1 MG Alameda Alliance for Health or Delegate J2354 SANDOSTATIN (OCTREOTIDE NON- DEPOT) 25 MCG Alameda Alliance for Health or Delegate J2357 XOLAIR (OMALIZUMAB) 5 MG Alameda Alliance for Health or Delegate J2503 MACUGEN (PEGAPTANIB SODIUM) 0.3 MG Alameda Alliance for Health or Delegate J2504 ADAGEN (PEGADEMASE BOVINE) 25 IU Alameda Alliance for Health or Delegate J2506 PEGFILGRASTIM (NEULASTA) NO BIOSIMILAR Alameda Alliance for Health or Delegate J2507 KRYSTEXXA (PEGLOTICASE) 1 MG Alameda Alliance for Health or Delegate J2562 MOZOBIL (PLERIXAFOR) 1 MG Alameda Alliance for Health or Delegate J2778 LUCENTIS (RANIBIZUMAB INJECTION) 0.1 MG Alameda Alliance for Health or Delegate J2793 ARCALYST (RILONACEPT) 1 MG Alameda Alliance for Health or Delegate J2796 NPLATE (ROMIPLOSTIM) 10 MCG Alameda Alliance for Health or Delegate J2797 ROLAPITANT 0.5 MG
Alameda Alliance for Health or Delegate J2820 LEUKINE (SARGRAMOSTIM) 50 MCG Alameda Alliance for Health or Delegate J2916 NA FERRIC GLUCONATE COMPLEX 12.5 MG Alameda Alliance for Health or Delegate J2941 INJECTION, SOMATROPIN, 1 MG Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 3 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J3111 ROMOSOZUMAB-AQQG (EVENITY) 1 MG Alameda Alliance for Health or Delegate J3240 THYROTROPIN
Alameda Alliance for Health or Delegate J3262 ACTEMRA (TOCILIZUMAB) 1 MG Alameda Alliance for Health or Delegate J3285 TREPROSTINIL 1 MG Alameda Alliance for Health or Delegate J3315 TRIPTORELIN PAMOATE 3.75 MG
Alameda Alliance for Health or Delegate J3357 STELARA (USTEKINUMAB) 1 MG Alameda Alliance for Health or Delegate J3380 VEDOLIZUMAB 1 MG Alameda Alliance for Health or Delegate J3385 VPRIV (VELAGLUCERASE ALFA) 100 UNITS Alameda Alliance for Health or Delegate J3396 VISUDYNE (VERTEPORFIN) 0.1 MG Alameda Alliance for Health or Delegate J3490 UNCLASSIFIED DRUGS Alameda Alliance for Health or Delegate J3490 TECENTRIQ Alameda Alliance for Health or Delegate J3490 with HUMIRA (ADALIMUMAB) 20 MG Alameda Alliance for Health or Delegate J3590 UNCLASSIFIED BIOLOGICS Alameda Alliance for Health or Delegate J7183 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, 1 I. U. VWF:RCO (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7185 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I. U. (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7186 INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN) (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7187 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7189 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7190 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I. U. (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 4 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J7191 FACTOR VIII AHF PORCINE PER IU (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7192 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISE SPECIFIED (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7193 FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON- RECOMBINANT) PER I. U. (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7194 FACTOR IX, COMPLEX, PER I. U. (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7195 FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I. U. (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7199 HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED (Alliance Group Care only; carved out to State for Medi-Cal) Alameda Alliance for Health or Delegate J7321 HYALGAN/SUPARTZ (HYALURONATE) PER DOSE Alameda Alliance for Health or Delegate J7322 HYMOVIS INJECTION 1 MG OR SYNVISC (HYALURONIC ACID) Alameda Alliance for Health or Delegate J7323 EUFLEXXA (SODIUM HYALURONATE) PER DOSE Alameda Alliance for Health or Delegate J7324 ORTHOVISC (HYALURONIC ACID) PER DOSE Alameda Alliance for Health or Delegate J7325 SYNVISC OR SYNVISC-ONE (HYALURONIC ACID), 1 MG Alameda Alliance for Health or Delegate J7326 GEL-ONE (HYALURONATE) Alameda Alliance for Health or Delegate J7336 CAPSAICIN 8% PATCH Alameda Alliance for Health or Delegate J7504 LYMPHCYT GLOB EQUINE PARNTRAL 250MG Alameda Alliance for Health or Delegate J7511 LYMPHCYT GLOB RABBIT PARNTRAL 25MG Alameda Alliance for Health or Delegate J7599 IMMUNOSUPPRESSIVE DRUG NOC (Alliance Group Care only; not covered by Medi-Cal) Alameda Alliance for Health or Delegate J7639 PULMOZYME (DORNASE ALFA) NON-COMP UNIT (Alliance Group Care only; not covered by Medi-Cal) Alameda Alliance for Health or Delegate J7682 TOBRAMYCIN INHAL NON-CP UNIT 300 MG (Alliance Group Care only; not covered by Medi-Cal) Alameda Alliance for Health or Delegate J7685 TOBRAMYCIN INHAL CP THRU DME 300 MG (Alliance Group Care only; not covered by Medi-Cal) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 5 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9000 DOXORUBICIN HCL, 10 MG
Alameda Alliance for Health or Delegate J9015 ALDESLEUKIN 10 MG Alameda Alliance for Health or Delegate J9017 ARSENIC TRIOXIDE 1 MG
Alameda Alliance for Health or Delegate J9019 ERWINAZE (ASPARAGINASE ERWINIA CHRYSANTHEMI) 1,000 IU Alameda Alliance for Health or Delegate J9020 ELSPAR (ASPARAGINASE) 10,000 UNITS Alameda Alliance for Health or Delegate J9021 ASPARAGINASE, RECOMBINANT, (RYLAZE) Alameda Alliance for Health or Delegate J9022 ATEZOLIZUMAB,10 MG
Alameda Alliance for Health or Delegate J9023 AVELUMAB, 10 MG
Alameda Alliance for Health or Delegate J9025 VIDAZA (AZACITIDINE) 1MG Alameda Alliance for Health or Delegate J9027 CLOFARABINE, 1 MG
Alameda Alliance for Health or Delegate J9030 BCG LIVE INTRAVESICAL INSTILLATION, 1 MG Alameda Alliance for Health or Delegate J9032 BELINOSTAT, 10MG
Alameda Alliance for Health or Delegate J9033 BENDAMUSTINE 1MG Alameda Alliance for Health or Delegate J9034 BENDEKA 1 MG Alameda Alliance for Health or Delegate J9035 BEVACIZUMAB 10 MG Alameda Alliance for Health or Delegate J9039 BLINATUMOMAB 1 MCG
Alameda Alliance for Health or Delegate J9041 BORTEZOMIB 0.1 MG
Alameda Alliance for Health or Delegate J9042 BRENTUXIMAB VEDOTIN 1 MG
Alameda Alliance for Health or Delegate J9043 CABAZITAXEL 1 MG
Alameda Alliance for Health or Delegate J9045 CARBOPLATIN 50 MG
Alameda Alliance for Health or Delegate J9047 CARFILZOMIB 1 MG
Alameda Alliance for Health or Delegate J9055 CETUXIMAB 10MG
Alameda Alliance for Health or Delegate J9057 COPANLISIB, 1 MG
Alameda Alliance for Health or Delegate J9060 CISPLATIN 10 MG INJECTION
Alameda Alliance for Health or Delegate J9065 CLADRIBINE PER 1 MG Alameda Alliance for Health or Delegate J9070 CYCLOPHOSPHAMIDE, 100 MG
Alameda Alliance for Health or Delegate J9119 CEMIPLIMAB-RWLC 1 MG Alameda Alliance for Health or Delegate J9144 DARATUMUMAB AND HYALURONIDASE-FIHJ (DARZALEX) Alameda Alliance for Health or Delegate J9145 DARATUMUMAB 10 MG
Alameda Alliance for Health or Delegate J9150 DAUNORUBICIN 10 MG
Alameda Alliance for Health or Delegate J9153 LIPOSOMAL, 1 MG DAUNORUBICIN AND 2.27 MG CYTARABINE Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 6 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9155 DEGARELIX INJECTION
Alameda Alliance for Health or Delegate J9160 ONTAK (DENILEUKIN DIFTITOX) 300 MCG Alameda Alliance for Health or Delegate J9171 DOCETAXEL 1 MG
Alameda Alliance for Health or Delegate J9173 DURVALUMAB, 10 MG
Alameda Alliance for Health or Delegate J9176 ELOTUZUMAB, 1MG
Alameda Alliance for Health or Delegate J9177 ENFORTUMAB VEDOTIN-EJFV, 0.25 MG (PADCEV) Alameda Alliance for Health or Delegate J9178 EPIRUBICIN HCL, 2 MG
Alameda Alliance for Health or Delegate J9179 ERIBULIN MESYLATE 0.1 MG Alameda Alliance for Health or Delegate J9181 ETOPOSIDE 10 MG Alameda Alliance for Health or Delegate J9185 FLUDARABINE PHOSPHATE, 50 MG
Alameda Alliance for Health or Delegate J9198 GEMCITABINE HYDROCHLORIDE, (INFUGEM), 100 MG Alameda Alliance for Health or Delegate J9201 GEMCITABINE HCL 200 MG
Alameda Alliance for Health or Delegate J9202 ZOLADEX (GOSERELIN ACETATE IMPLANT), PER 3.6 MG Alameda Alliance for Health or Delegate J9203 GEMTUZUMAB OZOGAMICIN 0.1 MG
Alameda Alliance for Health or Delegate J9204 MOGAMULIZUMAB-KPKC 1 MG Alameda Alliance for Health or Delegate J9205 IRINOTECAN LIPOSOME 1 MG
Alameda Alliance for Health or Delegate J9206 IRINOTECAN 20 MG
Alameda Alliance for Health or Delegate J9207 IXABEPILONE 1 MG
Alameda Alliance for Health or Delegate J9208 IFOSFAMIDE 1 GRAM
Alameda Alliance for Health or Delegate J9210 EMAPALUMAB-LZSG 1 MG Alameda Alliance for Health or Delegate J9214 INTERFERON ALFA2B, RECOMBINANT 1 MILL U Alameda Alliance for Health or Delegate J9217 LEUPROLIDE ACETATE, FOR DEPOT SUSP 7.5MG Alameda Alliance for Health or Delegate J9219 LEUPROLIDE ACETATE IMPLANT
Alameda Alliance for Health or Delegate J9227 ISATUXIMAB-IRFC Alameda Alliance for Health or Delegate J9228 YERVOY (IPILIMUMAB) 1 MG Alameda Alliance for Health or Delegate J9229 INOTUZUMAB OZOGAMICIN, 0.1 MG Alameda Alliance for Health or Delegate J9260 METHOTREXATE SODIUM, 50MG
Alameda Alliance for Health or Delegate J9261 NELARABINE 50 MG
Alameda Alliance for Health or Delegate J9263 OXALIPLATIN 0.5 MG
Alameda Alliance for Health or Delegate J9264 PACLITAXEL PROTEIN BOUND 1 MG Alameda Alliance for Health or Delegate J9266 ONCASPAR (PEGASPARGASE), PER SINGLE DOSE VIAL Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 7 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9267 PACLITAXEL 1 MG Alameda Alliance for Health or Delegate J9269 TAGRAXOFUSP-ERZS 10 MCG Alameda Alliance for Health or Delegate J9271 PEMBROLIZUMAB 1 MG Alameda Alliance for Health or Delegate J9280 MITOMYCIN, 5 MG
Alameda Alliance for Health or Delegate J9281 MITOMYCIN Alameda Alliance for Health or Delegate J9285 OLARATUMAB, 10 MG
Alameda Alliance for Health or Delegate J9293 MITOXANTRONE HYDROCHLORIDE PER 5 MG
Alameda Alliance for Health or Delegate J9295 NECITUMUMAB, 1 MG
Alameda Alliance for Health or Delegate J9299 NIVOLUMAB, 1 MG Alameda Alliance for Health or Delegate J9301 OBINUTUZUMAB 10 MG
Alameda Alliance for Health or Delegate J9302 OFATUMUMAB 10 MG
Alameda Alliance for Health or Delegate J9303 VECTIBIX (PANITUMUMAB) 10 MG Alameda Alliance for Health or Delegate J9304 INJECTION PEMETREXED PEMFEXY 10 MG Alameda Alliance for Health or Delegate J9305 PEMETREXED 10 MG Alameda Alliance for Health or Delegate J9306 PERJETA (PERTUZUMAB), 1 MG Alameda Alliance for Health or Delegate J9307 FOLOTYN (PRALATREXATE) 1 MG Alameda Alliance for Health or Delegate J9308 RAMUCIRUMAB 5 MG
Alameda Alliance for Health or Delegate J9309 POLATUZUMAB VEDOTIN-PIIQ, 1 MG Alameda Alliance for Health or Delegate J9311 RITUXIMAB, HYALURONIDASE Alameda Alliance for Health or Delegate J9312 RITUXIMAB, 10 MG Alameda Alliance for Health or Delegate J9313 MOXETUMOMAB PASUDOTOX-TDFK Alameda Alliance for Health or Delegate J9317 SACITUZUMAB GOVITECH-HZIY Alameda Alliance for Health or Delegate J9318 ROMIDEPSIN Alameda Alliance for Health or Delegate J9319 ROMIDEPSIN LYOPHILIZED Alameda Alliance for Health or Delegate J9325 TALIMOGENE LAHERPAREPVEC
Alameda Alliance for Health or Delegate J9328 TEMOZOLOMIDE 1 MG Alameda Alliance for Health or Delegate J9330 TEMSIROLIMUS 1 MG Alameda Alliance for Health or Delegate J9349 MONJUVI (tafasitamab-cxix) Alameda Alliance for Health or Delegate J9352 TRABECTEDIN 0.1MG
Alameda Alliance for Health or Delegate J9354 KADCYLA (ADO-TRASTUZUMAB EMTANSINE) 1MG Alameda Alliance for Health or Delegate J9355 HERCEPTIN (TRASTUZUMAB) EXCLUDE BIOSIMILAR 10 MG Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 8 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9356 HERCEPTIN HYLECTA (TRASTUZUMAB AND HYALURONIDASE-OYSK) SC INJECTION (600MG/10,000 UNITS) Alameda Alliance for Health or Delegate J9358 INJ FAM-TRSTUZUMB DRUXTCN-NXKI 1 MG Alameda Alliance for Health or Delegate J9370 VINCRISTINE SULFATE, 1 MG
Alameda Alliance for Health or Delegate J9371 VINCRISTINE SUL LIP 1MG
Alameda Alliance for Health or Delegate J9390 VINORELBINE TARTRATE, PER 10 MG
Alameda Alliance for Health or Delegate J9395 FULVESTRANT 25 MG
Alameda Alliance for Health or Delegate J9400 ZIV-AFLIBERCEPT 1MG
Alameda Alliance for Health or Delegate J9999 NOT OTHWISE CLASS ANTINEOPLSTC DRUG Alameda Alliance for Health or Delegate Q0138 INJ FERUMOXYTOL IDA 1 MG NON-ESRD Alameda Alliance for Health or Delegate Q0139 INJ FERUMOXYTOL TX IDA 1 MG ESRD Alameda Alliance for Health or Delegate Q2041 AXICABTAGENE CILOLEUCEL CAR Alameda Alliance for Health or Delegate Q2042 TISAGENLECLEUCEL CAR-POS T Alameda Alliance for Health or Delegate Q2043 TISAGENLECLEUCEL CAR-POS T Alameda Alliance for Health or Delegate Q2049 DOXORUBICIN HCL,LIPOSOMAL,LIPODOX 10MG
Alameda Alliance for Health or Delegate Q2050 PROVENGE (SIPULEUCEL -T) Alameda Alliance for Health or Delegate Q2053 BREXUCABTAGENE CAR POS T Alameda Alliance for Health or Delegate Q2054 LISOCABTAGENE CAR POS T Alameda Alliance for Health or Delegate Q2055 IDECABTAGENE VICLEUCEL Alameda Alliance for Health or Delegate Q4081 DOXORUBICIN HCL LIPOSOMAL Alameda Alliance for Health or Delegate Q5101 EPOETIN ALFA, 100 UNITS ESRD Alameda Alliance for Health or Delegate Q5103 INFLIXIMAB-DYYB (INFLECTRA) 10 MG BIOSIMILAR Alameda Alliance for Health or Delegate Q5104 INFLIXIMAB-ABDA, BIOSIMILAR, (RENFLEXIS), 10 MG Alameda Alliance for Health or Delegate Q5105 EPOETIN ALFA-EPBX 100 UNITS BIOSIMILAR, (RETACRIT) ESRD Alameda Alliance for Health or Delegate Q5106 EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS Alameda Alliance for Health or Delegate Q5107 BEVACIZUMAB-AWWB, BIOSIMILAR, (MVASI), 10 MG Alameda Alliance for Health or Delegate Q5108 PEGFILGRASTIM-JMDB, BIOSIMILAR, (FULPHILA), 0.5 MG Alameda Alliance for Health or Delegate Q5109 INJ INFLIXIMAB-QBTX BIOSIMILR 10 MG Alameda Alliance for Health or Delegate Q5110 FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM), 1 MICROGRAM Alameda Alliance for Health or Delegate Q5111 PEGFILGRASTIM-CBQV, BIOSIMILAR, (UDENYCA), 0.5 MG Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 9 of 10 UM_UM MED PROC CODES REQ PA 06/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Q5112 TRASTUZUMAB-DTTB, BIOSIMILAR, (ONTRUZANT), 10 MG
Alameda Alliance for Health or Delegate Q5113 TRASTUZUMAB-PKRB, BIOSIMILAR, (HERZUMA), 10 MG
Alameda Alliance for Health or Delegate Q5114 TRASTUZUMAB-DKST, BIOSIMILAR, (OGIVRI), 10 MG
Alameda Alliance for Health or Delegate Q5115 RITUXIMAB-ABBS, BIOSIMILAR, (TRUXIMA), 10 MG
Alameda Alliance for Health or Delegate Q5116 TRASTUZUMAB-QYYP, BIOSIMILAR, (TRAZIMERA), 10 MG Alameda Alliance for Health or Delegate Q5117 TRASTUZUMAB-ANNS, BIOSIMILAR, (KANJINTI), 10 MG
Alameda Alliance for Health or Delegate Q5118 BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG Alameda Alliance for Health or Delegate Q5119 RITUXIMAB-PVVR, BIOSIMILAR, (RUXIENCE), 10 MG Alameda Alliance for Health or Delegate Q5120 PEGFILGRASTIM-BMEZ, BIOSIMILAR, (ZIEXTENZO) 0.5 MG Alameda Alliance for Health or Delegate Q5121 INFLIXIMAB-AXXQ, BIOSIMILAR, (AVSOLA), 10 MG Alameda Alliance for Health or Delegate Q5122 PEGFILGRASTIM-JMDB, BIOSIMILAR, (FULPHILA), 0.5 MG Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 10 of 10 UM_UM MED PROC CODES REQ PA 06/2023