Prior authorization request form Form

Questions? Please call the Alliance Pharmacy Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4541 www.alamedaalliance.org RX_ OUTPATIENT INJECTABLE RX CODES 03/2021 Important Update: Outpatient Injectable Drug Codes that Require Prior Authorization (PA) 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 (UM) 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 Outpatient Injectable Drug codes that require prior authorization (PA).
This will affect claims with date(s) of service starting Saturday, May 1, 2021 and onward. Enclosed with this notice is a code specific list for Outpatient Injectable Drug codes that shows which codes require PA. The Outpatient Injectable Drug List can be found on our 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.
In addition to the codes, our claims system will also validate that claims received match the authorization when an 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 • NDC as published by the Food and Drug Administration (FDA) • Place of service matches site of care submitted on the authorization request form This update has been validated based on current and published billable coding for 2021 and was confirmed to be covered by the California Department of Health Care Services (DHCS).
If you have questions, please call the Alliance Provider Services Department at 1.510.747.4510. 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 Outpatient Injectable Drugs J0129 ORENCIA (ABATACEPT) 10 MG The Alliance or delegate group J0135 HUMIRA (ADALIMUMAB) 20 MG The Alliance or delegate group J0178 EYLEA (AFLIBERCEPT) 1 MG The Alliance or delegate group J0180 FABRAZYME (AGALSIDASE BETA) 1 MG
The Alliance or delegate group J0220 MYOZYME (ALGLUCOSIDASE ALFA) 10 MG The Alliance or delegate group J0221 LUMIZYME INJECTION (ALGLUCOSIDASE ALFA) 10 MG The Alliance or delegate group J0256 PROLASTIN (ALPHA 1 PROTEINASE INBITOR) 10 MG The Alliance or delegate group J0257 GLASSIA (ALPHA 1 PROTEINASE INBITOR) 10 MG The Alliance or delegate group J0480 SIMULECT (BASILIXIMAB) 10 MG The Alliance or delegate group J0485 NULOJIX (BELATACEPT) 1 MG The Alliance or delegate group J0585 BOTOX (ONABOTULINUMTOXINA), PER 1 UNIT
The Alliance or delegate group J0586 DYSPORT (ABOBOTULINUMTOXINA) 5 UNITS The Alliance or delegate group J0587 MYOBLOC (RIMABOTULINUMTOXINB), BOTULINUM TOXIN TYPE B, PER 100 UNITS
The Alliance or delegate group J0588 XEOMIN (INCOBOTULINUMTOXIN A) 1 UNIT The Alliance or delegate group J0597 BERINET (C-1 ESTERASE) 10 UNITS The Alliance or delegate group J0598 CINRYZE (C-1 ESTERASE) 10 UNITS The Alliance or delegate group J0638 ILARIS (CANAKINUMAB) 1 MG The Alliance or delegate group J0641 LEVOLEUCOVORIN 0.5 MG
The Alliance or delegate group J0717 CERTOLIZUMAB PEGOL 1MG
The Alliance or delegate group J0881 ARANESP (DARBEPOETIN ALFA, NON-ESRD) 1 MCG
The Alliance or delegate group J0882 DARBEPOETIN ALFA, ESRD USE 1 MCG
The Alliance or delegate group J0885 EPOETIN ALFA, NON-ESRD 1000 UNITS
The Alliance or delegate group J0887 MIRCERA (EPOETIN BETA) ESRD USE 1 MCG
The Alliance or delegate group J0897 PROLIA (DENOSUMAB) 1 MG The Alliance or delegate group J1300 SOLIRIS (ECULIZUMAB) 10 MG The Alliance or delegate group J1303 RAVULIZUMAB-CWVZ 10 MG The Alliance or delegate group ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR OUTPATIENT INJECTABLE DRUGS 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 Please note: This list does not include all services. Page 1 of 5 RX_BENEFIT PAD PA LIST 03/2021

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J1439 FERRIC CARBOXYMALTOS 1MG
The Alliance or delegate group J1442 FILGRASTIM G-CSF 1MCG
The Alliance or delegate group J1447 TBO FILGRASTIM (GRANIX) BIOSIMILAR 1 MCG The Alliance or delegate group J1453 FOSAPREPITANT 1.65 MG
The Alliance or delegate group J1458 NAGLAZYME (GALSULFASE) 1 MG The Alliance or delegate group J1459 IMMUNE GLOBULIN PRIVIGEN 500 MG
The Alliance or delegate group J1460 GAMMA GLOBULIN 1 ML
The Alliance or delegate group J1555 IMMUNE GLOBULIN CUVITRU 100 MG
The Alliance or delegate group J1556 IMMUNE GLOBULIN GLOB BIVIGAM 500MG
The Alliance or delegate group J1557 GAMMAPLEX (IMMUNE GLOBULIN) 500 MG The Alliance or delegate group J1559 HIZENTRA (IMMUNE GLOBULIN) 100 MG The Alliance or delegate group J1560 GAMMA GLOBULIN 10 ML The Alliance or delegate group J1561 GAMUNEX INJECTION, GAMUNEX-C/GAMMAKED (IMMUNE GLOBULIN) 500 MG
The Alliance or delegate group J1562 VIVAGLOBIN (IMMUNE GLOBULIN) 100 MG The Alliance or delegate group J1566 IMMUNE GLOBULIN, POWDER 500 MG The Alliance or delegate group J1568 OCTAGAM (IMMUNE GLOBULIN) 500 MG The Alliance or delegate group J1569 GAMMAGARD LIQUID (IMMUNE GLOBULIN) 500 MG The Alliance or delegate group J1572 FLEBOGAMMA (IMMUNE GLOBULIN) The Alliance or delegate group J1575 HYQVIA 100MG IMMUNEGLOBULIN 100 MG
The Alliance or delegate group J1599 IVIG NON-LYOPHILIZED, NOS IMMUNE GLOBULIN The Alliance or delegate group J1675 HISTRELIN ACETATE 10 MCG
The Alliance or delegate group J1726 MAKENA, 10 MG
The Alliance or delegate group J1743 ELAPRASE (IDURSULFASE) 1 MG The Alliance or delegate group J1745 REMICADE (INFLIXIMAB) EXCLUDE BIOSIMILAR 10 MG The Alliance or delegate group J1786 CEREZYME (IMUGLUCERASE) 10 UNITS The Alliance or delegate group J1826 INTERFERON BETA-1A INJ REBIF OR AVONEX 30 MCG
The Alliance or delegate group J1930 SOMATULINE DEPOT (LANREOTIDE) 1 MG
The Alliance or delegate group J1931 ALDURAZYME (LARONIDASE) 0.1MG
The Alliance or delegate group J1950 LEUPROLIDE ACETATE PER 3. 75 MG The Alliance or delegate group J2323 NATALIZUMAB 1 MG The Alliance or delegate group J2350 OCRELIZUMAB, 1MG
The Alliance or delegate group J2353 SANDOSTATIN (OCTREOTIDE, DEPOT) 1 MG The Alliance or delegate group J2354 SANDOSTATIN (OCTREOTIDE NON- DEPOT) 25 MCG The Alliance or delegate group Please note: This list does not include all services. Page 2 of 5 RX_BENEFIT PAD PA LIST 03/2021

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J2357 XOLAIR (OMALIZUMAB) 5 MG The Alliance or delegate group J2503 MACUGEN (PEGAPTANIB SODIUM) 0.3 MG The Alliance or delegate group J2504 ADAGEN (PEGADEMASE BOVINE) 25 IU
The Alliance or delegate group J2505 NEULASTA (PEGFILGRASTIM) 6 MG
The Alliance or delegate group J2507 KRYSTEXXA (PEGLOTICASE) 1 MG The Alliance or delegate group J2562 MOZOBIL (PLERIXAFOR) 1 MG The Alliance or delegate group J2778 LUCENTIS (RANIBIZUMAB INJECTION) 0.1 MG The Alliance or delegate group J2793 ARCALYST (RILONACEPT) 1 MG The Alliance or delegate group J2796 NPLATE (ROMIPLOSTIM) 10 MCG The Alliance or delegate group J2820 LEUKINE (SARGRAMOSTIM) 50 MCG The Alliance or delegate group J2916 NA FERRIC GLUCONATE COMPLEX 12.5 MG
The Alliance or delegate group J3111 ROMOSOZUMAB-AQQG (EVENITY) 1 MG The Alliance or delegate group J3262 ACTEMRA (TOCILIZUMAB) 1 MG The Alliance or delegate group J3285 TREPROSTINIL 1 MG
The Alliance or delegate group J3357 STELARA (USTEKINUMAB) 1 MG The Alliance or delegate group J3380 VEDOLIZUMAB 1 MG
The Alliance or delegate group J3385 VPRIV (VELAGLUCERASE ALFA) 100 UNITS The Alliance or delegate group J3396 VISUDYNE (VERTEPORFIN) 0.1 MG The Alliance or delegate group J7321 HYALGAN/SUPARTZ (HYALURONATE) PER DOSE
The Alliance or delegate group J7322 HYMOVIS INJECTION 1 MG OR SYNVISC (HYALURONIC ACID)
The Alliance or delegate group J7323 EUFLEXXA (SODIUM HYALURONATE) PER DOSE
The Alliance or delegate group J7324 ORTHOVISC (HYALURONIC ACID) PER DOSE
The Alliance or delegate group J7325 SYNVISC OR SYNVISC-ONE (HYALURONIC ACID), 1 MG
The Alliance or delegate group J7326 GEL-ONE (HYALURONATE) The Alliance or delegate group J7336 CAPSAICIN 8% PATCH
The Alliance or delegate group J7639 PULMOZYME (DORNASE ALFA) NON-COMP UNIT
The Alliance or delegate group J9015 ALDESLEUKIN 10 MG
The Alliance or delegate group J9019 ERWINAZE (ASPARAGINASE ERWINIA CHRYSANTHEMI) 1,000 IU The Alliance or delegate group J9020 ELSPAR (ASPARAGINASE) 10,000 UNITS The Alliance or delegate group J9025 VIDAZA (AZACITIDINE) 1MG
The Alliance or delegate group J9033 BENDAMUSTINE 1MG
The Alliance or delegate group J9034 BENDEKA 1 MG
The Alliance or delegate group J9035 BEVACIZUMAB 10 MG
The Alliance or delegate group Please note: This list does not include all services. Page 3 of 5 RX_BENEFIT PAD PA LIST 03/2021

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9160 ONTAK (DENILEUKIN DIFTITOX) 300 MCG
The Alliance or delegate group J9202 ZOLADEX (GOSERELIN ACETATE IMPLANT), PER 3.6 MG
The Alliance or delegate group J9214 INTERFERON ALFA2B, RECOMBINANT 1 MILL U The Alliance or delegate group J9217 LEUPROLIDE ACETATE, FOR DEPOT SUSP 7.5MG The Alliance or delegate group J9228 YERVOY (IPILIMUMAB) 1 MG
The Alliance or delegate group J9264 PACLITAXEL PROTEIN BOUND 1 MG
The Alliance or delegate group J9266 ONCASPAR (PEGASPARGASE), PER SINGLE DOSE VIAL
The Alliance or delegate group J9271 PEMBROLIZUMAB 1 MG
The Alliance or delegate group J9299 NIVOLUMAB, 1 MG
The Alliance or delegate group J9303 VECTIBIX (PANITUMUMAB) 10 MG
The Alliance or delegate group J9304 PEMETREXED (PEMFEXY), 10 MG The Alliance or delegate group J9305 PEMETREXED 10 MG The Alliance or delegate group J9306 PERJETA (PERTUZUMAB), 1 MG
The Alliance or delegate group J9307 FOLOTYN (PRALATREXATE) 1 MG
The Alliance or delegate group J9311 RITUXIMAB, HYALURONIDASE
The Alliance or delegate group J9312 RITUXIMAB, 10 MG
The Alliance or delegate group J9315 ISTODAX (ROMIDEPSIN)
The Alliance or delegate group J9354 KADCYLA (ADO-TRASTUZUMAB EMTANSINE) 1MG
The Alliance or delegate group J9355 HERCEPTIN (TRASTUZUMAB) EXCLUDE BIOSIMILAR 10 MG The Alliance or delegate group J9356 HERCEPTIN HYLECTA (TRASTUZUMAB AND HYALURONIDASE-OYSK) SC INJECTION (600MG/10,000 UNITS) The Alliance or delegate group J9358
INJ FAM-TRSTUZUMB DRUXTCN-NXKI 1 MG The Alliance or delegate group Q0138
INJ FERUMOXYTOL IDA 1 MG NON-ESRD The Alliance or delegate group Q0139
INJ FERUMOXYTOL TX IDA 1 MG ESRD The Alliance or delegate group Q2041 AXICABTAGENE CILOLEUCEL CAR
The Alliance or delegate group Q2042 TISAGENLECLEUCEL CAR-POS T
The Alliance or delegate group Q2043 PROVENGE (SIPULEUCEL -T) The Alliance or delegate group Q2050 DOXORUBICIN HCL LIPOSOMAL
The Alliance or delegate group Q4081 EPOETIN ALFA, 100 UNITS ESRD
The Alliance or delegate group Q5101 FILGRASTIM-SNDZ (ZARXIO) 1 MCG BIOSIMILAR
The Alliance or delegate group Q5103 INFLIXIMAB-DYYB (INFLECTRA) 10 MG BIOSIMILAR
The Alliance or delegate group Q5104 INFLIXIMAB-ABDA, BIOSIMILAR, (RENFLEXIS), 10 MG
The Alliance or delegate group Q5105 EPOETIN ALFA-EPBX 100 UNITS BIOSIMILAR, (RETACRIT) ESRD The Alliance or delegate group Please note: This list does not include all services. Page 4 of 5 RX_BENEFIT PAD PA LIST 03/2021

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Q5106 EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS
The Alliance or delegate group Q5107 BEVACIZUMAB-AWWB, BIOSIMILAR, (MVASI), 10 MG
The Alliance or delegate group Q5108 PEGFILGRASTIM-JMDB, BIOSIMILAR, (FULPHILA), 0.5 MG
The Alliance or delegate group Q5109 INFLIXIMAB-QBTX, BIOSIMILAR, (IXIFI), 10 MG
The Alliance or delegate group Q5110 FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM), 1 MICROGRAM
The Alliance or delegate group Q5111 PEGFILGRASTIM-CBQV, BIOSIMILAR, (UDENYCA), 0.5 MG
The Alliance or delegate group Q5112 TRASTUZUMAB-DTTB, BIOSIMILAR, (ONTRUZANT), 10 MG
The Alliance or delegate group Q5113 TRASTUZUMAB-PKRB, BIOSIMILAR, (HERZUMA), 10 MG
The Alliance or delegate group Q5114 TRASTUZUMAB-DKST, BIOSIMILAR, (OGIVRI), 10 MG
The Alliance or delegate group Q5115 RITUXIMAB-ABBS, BIOSIMILAR, (TRUXIMA), 10 MG
The Alliance or delegate group Q5116 TRASTUZUMAB-QYYP, BIOSIMILAR, (TRAZIMERA), 10 MG The Alliance or delegate group Q5117 TRASTUZUMAB-ANNS, BIOSIMILAR, (KANJINTI), 10 MG
The Alliance or delegate group Q5118 BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG The Alliance or delegate group Q5119 RITUXIMAB-PVVR, BIOSIMILAR, (RUXIENCE), 10 MG The Alliance or delegate group Q5120 PEGFILGRASTIM-BMEZ, BIOSIMILAR, (ZIEXTENZO) 0.5 MG The Alliance or delegate group Q5121 INFLIXIMAB-AXXQ, BIOSIMILAR, (AVSOLA), 10 MG The Alliance or delegate group Please note: This list does not include all services. Page 5 of 5 RX_BENEFIT PAD PA LIST 03/2021