Prior authorization request form Form

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Important Update: Utilization Management (UM) Medication (Physician-Administered Drugs, PAD) That Require Prior 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 physician-administered drugs (PAD) codes that require prior authorization for in-network providers. This list is dynamic and may change based on new medicines coming to the market and to improve our health plan services. This does not include outpatient pharmacy services through the member’s pharmacy benefit. Providers should follow billing instructions for non-capitated services, fee-for-service (FFS) Medi- Cal or special programs, as specified in the policy sections of the Medi-Cal provider manuals. Examples of non-capitated drugs may include but are not limited to:
• Selected HIV/AIDS/hepatitis B treatment drugs • Alcohol and heroin detoxification and dependency treatment drugs • Blood factors:
o Clotting Factor Disorder Treatment o Psychiatric drugs Enclosed with this notice is an updated code-specific list indicating which codes now require prior authorization. The newly added codes will impact claims with the date(s) of service starting Monday, May 19, 2025, and thereafter. The 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 prior 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 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. The Alliance uses code-auditing software for automated claims

Questions? Please call the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4510 www.alamedaalliance.org 2/2 UMPRVDRUM MED AUTH UPDATE 03/2025 FAXED: 4/29/2025 coding verification, and to ensure that the Alliance is processing claims in compliance with general industry and Medi-Cal standards. In addition to the codes, our claims system will 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 2025. 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) Alameda Alliance for Health or Delegate J0178 EYLEA (AFLIBERCEPT) Alameda Alliance for Health or Delegate J0180 FABRAZYME (AGALSIDASE BETA) Alameda Alliance for Health or Delegate J0185 APREPITANT (CINVANTI)
Alameda Alliance for Health or Delegate J0217 VELMANASE ALFA-TYCV (LAMZEDE) Alameda Alliance for Health or Delegate J0219 AVALGLUCOSIDASE ALFA-NGPT (NEXVIAZYME) Alameda Alliance for Health or Delegate J0220 MYOZYME (ALGLUCOSIDASE ALFA) Alameda Alliance for Health or Delegate J0221 LUMIZYME INJECTION (ALGLUCOSIDASE ALFA) Alameda Alliance for Health or Delegate J0222 PATISIRAN (ONPATTRO) Alameda Alliance for Health or Delegate J0224 OXLUMO (LUMASIRAN) Alameda Alliance for Health or Delegate J0225 VUTRISIRAN (AMVUTTRA) Alameda Alliance for Health or Delegate J0256 PROLASTIN (ALPHA 1 PROTEINASE INBITOR) Alameda Alliance for Health or Delegate J0257 GLASSIA (ALPHA 1 PROTEINASE INBITOR) Alameda Alliance for Health or Delegate J0480 SIMULECT (BASILIXIMAB) Alameda Alliance for Health or Delegate J0485 NULOJIX (BELATACEPT) Alameda Alliance for Health or Delegate J0585 BOTOX (ONABOTULINUMTOXINA) Alameda Alliance for Health or Delegate J0586 DYSPORT (ABOBOTULINUMTOXINA) Alameda Alliance for Health or Delegate J0587 MYOBLOC (RIMABOTULINUMTOXINB), BOTULINUM TOXIN TYPE B Alameda Alliance for Health or Delegate Alameda Alliance for Health Referral and Prior Authorization (PA) Procedure Codes Utilization Management (UM) Medications 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 The newly added procedure codes requiring PA effective Monday, May 19, 2025, and onward, are listed below in bold font. UM Medications Please note: This list does not include all services. Page 1 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J0588 XEOMIN (INCOBOTULINUMTOXIN A) Alameda Alliance for Health or Delegate J0597 BERINERT (C-1 ESTERASE) Alameda Alliance for Health or Delegate J0598 CINRYZE (C-1 ESTERASE) Alameda Alliance for Health or Delegate J0638 ILARIS (CANAKINUMAB) Alameda Alliance for Health or Delegate J0641 LEVOLEUCOVORIN (Fusilev, Khapzory) Alameda Alliance for Health or Delegate J0717 CERTOLIZUMAB PEGOL (CIMZIA) Alameda Alliance for Health or Delegate J0801 CORTICOTROPIN (ACTHAR GEL) Alameda Alliance for Health or Delegate J0802 CORTICOTROPIN (ANI) Alameda Alliance for Health or Delegate J0881 DARBEPOETIN ALFA (ARANESP, NON-ESRD) Alameda Alliance for Health or Delegate J0882 DARBEPOETIN ALFA (ARANESP, ESRD) Alameda Alliance for Health or Delegate J0885 EPOETIN ALFA (EPOETIN,NON-ESRD) Alameda Alliance for Health or Delegate J0887 EPOETIN BETA (MIRCERA, ESRD) Alameda Alliance for Health or Delegate J0894 DECITABINE (Dacogen)
Alameda Alliance for Health or Delegate J0897 PROLIA (DENOSUMAB) Alameda Alliance for Health or Delegate J1300 SOLIRIS (ECULIZUMAB) Alameda Alliance for Health or Delegate J1303 RAVULIZUMAB-CWVZ (ULTOMIRIS) Alameda Alliance for Health or Delegate J1304 TOFERSEN (QALSODY) Alameda Alliance for Health or Delegate J1411 ETRANACOGENE DEZAPARVOVEC (HEMGENIX) Alameda Alliance for Health or Delegate J1412 VALOCTOCOGENE ROXAPARVOVEC-RVOX (ROCTAVIAN) Alameda Alliance for Health or Delegate J1413 DELANDISTROGENE MOXEPARVOVEC (ELEVIDYS) Alameda Alliance for Health or Delegate J1414 FIDANACOGENE ELEPARVOVEC (BEQVEZ) Alameda Alliance for Health or Delegate J1439 FERRIC CARBOXYMALTOSE (INJECTAFER) Alameda Alliance for Health or Delegate J1442 FILGRASTIM G-CSF (NEUPOGEN) Alameda Alliance for Health or Delegate J1447 TBO FILGRASTIM (GRANIX) BIOSIMILAR Alameda Alliance for Health or Delegate J1449 ROLVEDON (EFLAPEGRASTIM-XNST) Alameda Alliance for Health or Delegate J1454 FOSNETUPITANT AND PALONOSETRON (AKYNZEO)
Alameda Alliance for Health or Delegate J1456 FOSAPREPITANT (TEVA) Alameda Alliance for Health or Delegate J1458 NAGLAZYME (GALSULFASE) Alameda Alliance for Health or Delegate J1459 IMMUNE GLOBULIN (PRIVIGEN) Alameda Alliance for Health or Delegate J1460 GAMMA GLOBULIN (GAMASTAN) 1ML Alameda Alliance for Health or Delegate J1555 IMMUNE GLOBULIN (CUVITRU) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 2 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J1556 IMMUNE GLOBULIN (BIVIGAM) Alameda Alliance for Health or Delegate J1557 IMMUNE GLOBULIN (GAMMAPLEX) Alameda Alliance for Health or Delegate J1559 IMMUNE GLOBULIN (HIZENTRA) Alameda Alliance for Health or Delegate J1560 IMMUNE GLOBULIN (GAMASTAN) 10ML Alameda Alliance for Health or Delegate J1561 IMMUNE GLOBULIN (GAMUNEX INJECTION, GAMUNEX-C/GAMMAKED ) Alameda Alliance for Health or Delegate J1562 IMMUNE GLOBULIN (VIVAGLOBIN) Alameda Alliance for Health or Delegate J1566 IMMUNE GLOBULIN (Carimune NF, Panglobulin NF and Gammagard S/D) Alameda Alliance for Health or Delegate J1568 IMMUNE GLOBULIN (OCTAGAM ) Alameda Alliance for Health or Delegate J1569 IMMUNE GLOBULIN (GAMMAGARD LIQUID) Alameda Alliance for Health or Delegate J1571 HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B) Alameda Alliance for Health or Delegate J1572 IMMUNE GLOBULIN (FLEBOGAMMA) Alameda Alliance for Health or Delegate J1575 IMMUNEGLOBULIN (HYQVIA) Alameda Alliance for Health or Delegate J1599 IVIG NON-LYOPHILIZED, NOS IMMUNE GLOBULIN (ALYGLO) Alameda Alliance for Health or Delegate J1675 HISTRELIN ACTETATE Alameda Alliance for Health or Delegate J1743 ELAPRASE (IDURSULFASE) Alameda Alliance for Health or Delegate J1745 REMICADE (INFLIXIMAB) EXCLUDE BIOSIMILAR Alameda Alliance for Health or Delegate J1786 CEREZYME (IMIGLUCERASE) Alameda Alliance for Health or Delegate J1826 INTERFERON BETA-1A (REBIF OR AVONEX) Alameda Alliance for Health or Delegate J1930 SOMATULINE DEPOT (LANREOTIDE) Alameda Alliance for Health or Delegate J1931 ALDURAZYME (LARONIDASE) Alameda Alliance for Health or Delegate J1950 LEUPROLIDE ACETATE PER 3. 75 MG (LUPRON) Alameda Alliance for Health or Delegate J2323 NATALIZUMAB (TYSARBI) Alameda Alliance for Health or Delegate J2326 SPINRAZA (NUSINERSEN) Alameda Alliance for Health or Delegate J2350 OCRELIZUMAB (OCREVUS) 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) Alameda Alliance for Health or Delegate J2503 MACUGEN (PEGAPTANIB SODIUM) Alameda Alliance for Health or Delegate J2504 ADAGEN (PEGADEMASE BOVINE) Alameda Alliance for Health or Delegate J2506 PEGFILGRASTIM (NEULASTA) NO BIOSIMILAR Alameda Alliance for Health or Delegate J2507 KRYSTEXXA (PEGLOTICASE) Alameda Alliance for Health or Delegate J2508 PEGUNIGALSIDASE ALFA-IWXJ (ELFABRIO) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 3 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J2562 MOZOBIL (PLERIXAFOR) Alameda Alliance for Health or Delegate J2778 LUCENTIS (RANIBIZUMAB INJECTION) Alameda Alliance for Health or Delegate J2793 ARCALYST (RILONACEPT) Alameda Alliance for Health or Delegate J2796 NPLATE (ROMIPLOSTIM) Alameda Alliance for Health or Delegate J2797 ROLAPITANT Alameda Alliance for Health or Delegate J2820 LEUKINE (SARGRAMOSTIM) Alameda Alliance for Health or Delegate J2916 NA FERRIC GLUCONATE COMPLEX (FERRLECIT) Alameda Alliance for Health or Delegate J1301 RADICAVA (EDARAVONE) Alameda Alliance for Health or Delegate J3111 ROMOSOZUMAB-AQQG (EVENITY) Alameda Alliance for Health or Delegate J3240 THYROTROPIN (THYROGEN)
Alameda Alliance for Health or Delegate J3262 ACTEMRA (TOCILIZUMAB) Alameda Alliance for Health or Delegate J3285 TREPROSTINIL (REMODULIN) Alameda Alliance for Health or Delegate J3315 TRIPTORELIN PAMOATE (TRELSTAR)
Alameda Alliance for Health or Delegate J3357 STELARA (USTEKINUMAB) Alameda Alliance for Health or Delegate J3380 VEDOLIZUMAB (ENTYVIO) Alameda Alliance for Health or Delegate J3385 VPRIV (VELAGLUCERASE ALFA) Alameda Alliance for Health or Delegate J3392 EXAGAMGLOGENE AUTOTEMCEL (CASGEVY) Alameda Alliance for Health or Delegate J3393 BETIBEGLOGENE AUTOTEMCEL (ZYNTEGLO) Alameda Alliance for Health or Delegate J3394 LOVOTIBEGLOGENE AUTOTEMCEL (LYFGENIA) Alameda Alliance for Health or Delegate J3396 VISUDYNE (VERTEPORFIN) Alameda Alliance for Health or Delegate J3398 VORETIGENE NEPARVOVEC-RZYL (LUXTURNA) Alameda Alliance for Health or Delegate J3399 ONASEMNOGENE ABEPAR (ZOLGENSMA) Alameda Alliance for Health or Delegate J3590 UNCLASSIFIED BIOLOGICS Alameda Alliance for Health or Delegate J3401 BEREMEAGENE GEPERPAVEC-SVDT (VYJUVEK) Alameda Alliance for Health or Delegate J7183 VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, 1 I. U. VWF:RCO (Alliance Group Care only; carved out to State for Medi-Cal FFS Intermediary) Alameda Alliance for Health or Delegate J7185 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I. U. (Alliance Group Care only; carved out to State for Medi-Cal FFS Intermediary) Alameda Alliance for Health or Delegate J7186 ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 4 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J7187 VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO (Alliance Group Care only; carved out to State for Medi-Cal FFS Intermediary) Alameda Alliance for Health or Delegate J7189 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM 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 FFS Intermediary) 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 FFS Intermediary) 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 FFS Intermediary) Alameda Alliance for Health or Delegate J7194 FACTOR IX, COMPLEX, PER I. U. (Alliance Group Care only; carved out to State for Medi-Cal FFS Intermediary) 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 FFS Intermediary) Alameda Alliance for Health or Delegate J7199 HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED (Alliance Group Care only; carved out to State for Medi-Cal FFS Intermediary) Alameda Alliance for Health or Delegate J7321 HYALGAN/SUPARTZ (HYALURONATE) PER DOSE Alameda Alliance for Health or Delegate J7322 HYMOVIS 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) 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 J9000 DOXORUBICIN HCL (ADRIAMYCIN) Alameda Alliance for Health or Delegate J9015 ALDESLEUKIN (PROLEUKIN) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 5 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9017 ARSENIC TRIOXIDE (TRISENOX)
Alameda Alliance for Health or Delegate J9019 ERWINAZE (ASPARAGINASE ERWINIA CHRYSANTHEMI) Alameda Alliance for Health or Delegate J9020 ELSPAR (ASPARAGINASE) Alameda Alliance for Health or Delegate J9021 ASPARAGINASE, RECOMBINANT, (RYLAZE) Alameda Alliance for Health or Delegate J9022 ATEZOLIZUMAB (TECENTRIQ)
Alameda Alliance for Health or Delegate J9023 AVELUMAB (BAVENCIO)
Alameda Alliance for Health or Delegate J9025 VIDAZA (AZACITIDINE) Alameda Alliance for Health or Delegate J9027 CLOFARABINE (CLOLAR)
Alameda Alliance for Health or Delegate J9029 NADOFARAGENE FIRADENOVEC-VNCG (ADSTILADRIN) Alameda Alliance for Health or Delegate J9030 BCG LIVE INTRAVESICAL INSTILLATION Alameda Alliance for Health or Delegate J9032 BELINOSTAT (BELEODAQ)
Alameda Alliance for Health or Delegate J9033 BENDAMUSTINE (TREANDA) Alameda Alliance for Health or Delegate J9034 BENDAMUSTINE (BENDEKA) Alameda Alliance for Health or Delegate J9035 BEVACIZUMAB (AVASTIN) Alameda Alliance for Health or Delegate J9039 BLINATUMOMAB (BLINCYTO)
Alameda Alliance for Health or Delegate J9041 BORTEZOMIB (VELCADE)
Alameda Alliance for Health or Delegate J9042 BRENTUXIMAB VEDOTIN (ADCETRIS)
Alameda Alliance for Health or Delegate J9043 CABAZITAXEL (JEVTANA)
Alameda Alliance for Health or Delegate J9045 CARBOPLATIN (PARAPLATIN)
Alameda Alliance for Health or Delegate J9047 CARFILZOMIB (KYPROLIS)
Alameda Alliance for Health or Delegate J9055 CETUXIMAB (ERBITUX)
Alameda Alliance for Health or Delegate J9060 CISPLATIN (PLATINOL)
Alameda Alliance for Health or Delegate J9065 CLADRIBINE (LEUSTATIN) Alameda Alliance for Health or Delegate J9072 CYCLOPHOSPHAMIDE (DR.REDDY'S)
Alameda Alliance for Health or Delegate J9119 CEMIPLIMAB-RWLC (LIBTAYO) Alameda Alliance for Health or Delegate J9144 DARATUMUMAB AND HYALURONIDASE-FIHJ (DARZALEX FASPRO) Alameda Alliance for Health or Delegate J9145 DARATUMUMAB (DARZALEX)
Alameda Alliance for Health or Delegate J9150 DAUNORUBICIN
Alameda Alliance for Health or Delegate J9153 LIPOSOMAL DAUNORUBICIN AND CYTARABINE (VYXEOS) Alameda Alliance for Health or Delegate J9155 DEGARELIX (FIRMAGON)
Alameda Alliance for Health or Delegate J9171 DOCETAXEL (TAXOTERE)
Alameda Alliance for Health or Delegate J9173 DURVALUMAB (IMFINZI)
Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 6 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9176 ELOTUZUMAB (EMPLICITI)
Alameda Alliance for Health or Delegate J9177 ENFORTUMAB VEDOTIN-EJFV (PADCEV) Alameda Alliance for Health or Delegate J9178 EPIRUBICIN HCL (ELLENCE)
Alameda Alliance for Health or Delegate J9179 ERIBULIN MESYLATE (HALAVEN) Alameda Alliance for Health or Delegate J9181 ETOPOSIDE (TOPOSAR) Alameda Alliance for Health or Delegate J9185 FLUDARABINE PHOSPHATE (FLUDARA)
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 (MYLOTARG)
Alameda Alliance for Health or Delegate J9204 MOGAMULIZUMAB-KPKC (POTELIGEO) Alameda Alliance for Health or Delegate J9205 IRINOTECAN LIPOSOME (ONIVYDE)
Alameda Alliance for Health or Delegate J9206 IRINOTECAN (CAMPTOSAR)
Alameda Alliance for Health or Delegate J9207 IXABEPILONE (IXEMPRA)
Alameda Alliance for Health or Delegate J9208 IFOSFAMIDE (IFEX)
Alameda Alliance for Health or Delegate J9210 EMAPALUMAB-LZSG (GAMIFANT) Alameda Alliance for Health or Delegate J9214 INTERFERON ALFA2B, RECOMBINANT (INTRON A) 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 (SARCLISA) Alameda Alliance for Health or Delegate J9228 YERVOY (IPILIMUMAB) Alameda Alliance for Health or Delegate J9229 INOTUZUMAB OZOGAMICIN (BESPONSA) Alameda Alliance for Health or Delegate J9258 PACLITAXEL PROTEIN-BOUND PARTICLES (TEVA) Alameda Alliance for Health or Delegate J9259 PACLITAXEL PROTEIN-BOUND PARTICLES (AMERICAN REGENT) Alameda Alliance for Health or Delegate J9260 METHOTREXATE SODIUM
Alameda Alliance for Health or Delegate J9261 NELARABINE (ARRANON)
Alameda Alliance for Health or Delegate J9263 OXALIPLATIN (ELOXATIN)
Alameda Alliance for Health or Delegate J9264 PACLITAXEL PROTEIN BOUND (ABRAXANE) Alameda Alliance for Health or Delegate J9266 ONCASPAR (PEGASPARGASE), PER SINGLE DOSE VIAL Alameda Alliance for Health or Delegate J9267 PACLITAXEL (TAXOL) Alameda Alliance for Health or Delegate J9269 TAGRAXOFUSP-ERZS Alameda Alliance for Health or Delegate J9271 PEMBROLIZUMAB (KEYTRUDA) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 7 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9280 MITOMYCIN 5 MG
Alameda Alliance for Health or Delegate J9281 MITOMYCIN 1MG (JELMYTO) Alameda Alliance for Health or Delegate J9285 OLARATUMAB (LARTRUVO)
Alameda Alliance for Health or Delegate J9286 GLOFITAMAB-GXBM (COLUMVI) Alameda Alliance for Health or Delegate J9293 MITOXANTRONE HYDROCHLORIDE
Alameda Alliance for Health or Delegate J9295 NECITUMUMAB (PORTRAZZA)
Alameda Alliance for Health or Delegate J9299 NIVOLUMAB (OPDIVO) Alameda Alliance for Health or Delegate J9301 OBINUTUZUMAB 10 MG
Alameda Alliance for Health or Delegate J9302 OFATUMUMAB (ARZERRA)
Alameda Alliance for Health or Delegate J9303 VECTIBIX (PANITUMUMAB) Alameda Alliance for Health or Delegate J9304 PEMETREXED (PEMFEXY) Alameda Alliance for Health or Delegate J9305 PEMETREXED (ALIMTA) Alameda Alliance for Health or Delegate J9306 PERJETA (PERTUZUMAB) Alameda Alliance for Health or Delegate J9307 FOLOTYN (PRALATREXATE) Alameda Alliance for Health or Delegate J9308 RAMUCIRUMAB (CYRAMZA)
Alameda Alliance for Health or Delegate J9309 POLATUZUMAB VEDOTIN-PIIQ (POLIVY) Alameda Alliance for Health or Delegate J9311 RITUXIMAB, HYALURONIDASE (RITUXAN HYCELA) Alameda Alliance for Health or Delegate J9312 RITUXIMAB (RITUXAN) Alameda Alliance for Health or Delegate J9313 MOXETUMOMAB PASUDOTOX-TDFK (LUMOXITI) Alameda Alliance for Health or Delegate J9317 SACITUZUMAB GOVITECH-HZIY (TRODELVY) Alameda Alliance for Health or Delegate J9318 ROMIDEPSIN NON-LYOPHILIZED Alameda Alliance for Health or Delegate J9319 ROMIDEPSIN LYOPHILIZED Alameda Alliance for Health or Delegate J9321 EPCORITAMAB-BYSP (EPKINLY) Alameda Alliance for Health or Delegate J9322 PEMETREXED (BLUEPOINT) Alameda Alliance for Health or Delegate J9323 PEMETREXED (HOSPIRA) Alameda Alliance for Health or Delegate J9324 PEMETREXED (PEMRYDI RTU) Alameda Alliance for Health or Delegate J9325 TALIMOGENE LAHERPAREPVEC (IMLYGIC)
Alameda Alliance for Health or Delegate J9328 TEMOZOLOMIDE (TEMODAR) Alameda Alliance for Health or Delegate J9330 TEMSIROLIMUS (TORISEL) Alameda Alliance for Health or Delegate J9333 ROZANOLIXIZUMAB-NOLI (RYSTIGGO) Alameda Alliance for Health or Delegate J9334 EFGARTIGIMOD ALFA-FCAB AND HYALURONIDASE-QVFC (VYVGART) Alameda Alliance for Health or Delegate J9349 TAFASITAMAB-CXIX (MONJUVI) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 8 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO J9350 MOSUNETUZUMAB-AXGB (LUNSUMIO) Alameda Alliance for Health or Delegate J9352 TRABECTEDIN (YONDELIS)
Alameda Alliance for Health or Delegate J9354 KADCYLA (ADO-TRASTUZUMAB EMTANSINE) Alameda Alliance for Health or Delegate J9355 HERCEPTIN (TRASTUZUMAB) EXCLUDE BIOSIMILAR Alameda Alliance for Health or Delegate J9356 HERCEPTIN HYLECTA (TRASTUZUMAB AND HYALURONIDASE-OYSK) SC Alameda Alliance for Health or Delegate J9358 FAM-TRSTUZUMB DRUXTCN-NXKI (ENHERTU) Alameda Alliance for Health or Delegate J9370 VINCRISTINE SULFATE (VINCASAR)
Alameda Alliance for Health or Delegate J9371 VINCRISTINE SUL LIP (MARQIBO)
Alameda Alliance for Health or Delegate J9380 TECLISTAMAB-CGYV (TECVAYLI) Alameda Alliance for Health or Delegate J9381 TEPLIZUMAB-MZWV (TZIELD) Alameda Alliance for Health or Delegate J9390 VINORELBINE TARTRATE (NAVELBINE)
Alameda Alliance for Health or Delegate J9395 FULVESTRANT (FASLODEX)
Alameda Alliance for Health or Delegate J9400 ZIV-AFLIBERCEPT (ZALTRAP) Alameda Alliance for Health or Delegate Q0138 FERUMOXYTOL (FERUMOXYTO, NON-ESRD) Alameda Alliance for Health or Delegate Q0139 FERUMOXYTOL (FERUMOXYTO, ESRD) Alameda Alliance for Health or Delegate Q2041 AXICABTAGENE CILOLEUCEL (YESCARTA) Alameda Alliance for Health or Delegate Q2042 TISAGENLECLEUCEL (KYMRIAH) Alameda Alliance for Health or Delegate Q2043 PROVENGE (SIPULEUCEL -T) Alameda Alliance for Health or Delegate Q2049 DOXORUBICIN HCL,LIPOSOMAL (LIPODOX) Alameda Alliance for Health or Delegate Q2050 DOXORUBICIN HCL LIPOSOMAL (DOXIL) Alameda Alliance for Health or Delegate Q2053 BREXUCABTAGENE (TECARTUS) Alameda Alliance for Health or Delegate Q2054 LISOCABTAGENE MARALEUCEL (BREYANZI) Alameda Alliance for Health or Delegate Q2055 IDECABTAGENE VICLEUCEL (ABECMA) Alameda Alliance for Health or Delegate Q2056 CILTACABTAGENE AUTOLEUCEL (CARVYKTI) Alameda Alliance for Health or Delegate Q2057 AFAMITRESGENE AUTOLEUCEL (TECELRA) Alameda Alliance for Health or Delegate Q4081 EPOETIN ALFA (EPOETIN, for ESRD on dialysis) Alameda Alliance for Health or Delegate Q5101 FILGRASTIM-SNDZ (ZARXIO) BIOSIMILAR Alameda Alliance for Health or Delegate Q5103 INFLIXIMAB-DYYB (INFLECTRA) BIOSIMILAR Alameda Alliance for Health or Delegate Q5104 INFLIXIMAB-ABDA, BIOSIMILAR, (RENFLEXIS) Alameda Alliance for Health or Delegate Q5105 EPOETIN ALFA-EPBX BIOSIMILAR, (RETACRIT) ESRD Alameda Alliance for Health or Delegate Q5106 EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE) Alameda Alliance for Health or Delegate Q5107 BEVACIZUMAB-AWWB, BIOSIMILAR, (MVASI) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 9 of 10 UM_MED PROC CODES REQ PA-UM 03/2025

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Q5108 PEGFILGRASTIM-JMDB, BIOSIMILAR, (FULPHILA) Alameda Alliance for Health or Delegate Q5109 INFLIXIMAB-QBTX BIOSIMILR (IXIFI) Alameda Alliance for Health or Delegate Q5110 FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM) Alameda Alliance for Health or Delegate Q5111 PEGFILGRASTIM-CBQV, BIOSIMILAR, (UDENYCA) Alameda Alliance for Health or Delegate Q5112 TRASTUZUMAB-DTTB, BIOSIMILAR, (ONTRUZANT) Alameda Alliance for Health or Delegate Q5113 TRASTUZUMAB-PKRB, BIOSIMILAR, (HERZUMA) Alameda Alliance for Health or Delegate Q5114 TRASTUZUMAB-DKST, BIOSIMILAR, (OGIVRI) Alameda Alliance for Health or Delegate Q5115 RITUXIMAB-ABBS, BIOSIMILAR, (TRUXIMA) Alameda Alliance for Health or Delegate Q5116 TRASTUZUMAB-QYYP, BIOSIMILAR, (TRAZIMERA) Alameda Alliance for Health or Delegate Q5117 TRASTUZUMAB-ANNS, BIOSIMILAR, (KANJINTI) Alameda Alliance for Health or Delegate Q5118 BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV) Alameda Alliance for Health or Delegate Q5119 RITUXIMAB-PVVR, BIOSIMILAR, (RUXIENCE) Alameda Alliance for Health or Delegate Q5120 PEGFILGRASTIM-BMEZ, BIOSIMILAR, (ZIEXTENZO) Alameda Alliance for Health or Delegate Q5121 INFLIXIMAB-AXXQ, BIOSIMILAR, (AVSOLA) Alameda Alliance for Health or Delegate Q5122 PEGFILGRASTIM-APGF (NYVPERIA) BIOSIMILAR Alameda Alliance for Health or Delegate Q5126 BEVACIZUMAB-MALY (ALYMSYS) BIOSIMILAR Alameda Alliance for Health or Delegate Q5127 PEGFILGRASTIM-FPGK (STIMUFEND) BIOSIMILAR Alameda Alliance for Health or Delegate Q5128 RANIBIZUMAB-EQRN (CIMERLI), BIOSIMILAR Alameda Alliance for Health or Delegate Q5129 BEVACIZUMAB-ADCD (VEGZELMA), BIOSIMILAR Alameda Alliance for Health or Delegate Q5130 PEGFILGRASTIM-PBBK (FYLNETRA), BIOSIMILAR Alameda Alliance for Health or Delegate Q5131 ADALIMUMAB-AACF (IDACIO) Alameda Alliance for Health or Delegate S0013 ESKETAMINE (SPRAVATO) Alameda Alliance for Health or Delegate UM Medications (cont.) Please note: This list does not include all services. Page 10 of 10 UM_MED PROC CODES REQ PA-UM 03/2025