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Injectable Medications subject to Medical Necessity and Appropriateness Review (MNAR)

Magellan Rx Management performs MNAR of the injectable medications listed within the following therapeutic categories as part of the Horizon BCBSNJ Medical Injectables Program (MIP). This list was last revised on November 28, 2022 and is subject to change.

Select a therapeutic category to review the injectable medications information. Lisitings within each category are organized alphabetically by generic drug name.

For the unclassified drugs in this listing, please include the appropriate National Drug Code (NDC) when interacting with MRxM and when submitting claims.

Acute Hepatic Porphyria

Amyloidosis

Amyotrophic Lateral Sclerosis

Anemia

Anemia (Dialysis)

Antipruritic (Dialysis)

Anti-emetics

Asthma

Auto-inflammatory Conditions

Chemotherapy Protectant

Duchenne Muscular Distrophy

Endocrine Disorders

Enzyme Deficiency

Erythropoietic protoporphyria

Hemophilia

Hematologic Disorders

Hereditary Angioedema

HIV/AIDS

Immunodeficiency

Inflammatory Conditions

Mental Health

Metabolic Conditions

Migraine

Multiple Sclerosis

Myelodysplastic Syndrome

Neutropenia

Ocular Conditions

Oncology

Osteoarthritis

Osteoporosis

Primary Hyperoxaluria

Sickle Cell Disease

Spinal Muscular Atrophy

Thrombocytopenia

Thyroid Eye Disease

Acute Hepatic Porphyria

Generic Medication Name

Medication Brand Name

HCPCS Code

givosiran

Givlaari®

J0223

Amyloidosis

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

patisiran

Onpattro®

J0222

vutrisiran Amvuttra™ J3490 71336-1003-01

Recent program changes:

  • Amvuttra is effective 1/23/2023 as part of this program

Amyotrophic Lateral Sclerosis

Generic Medication Name

Medication Brand Name

HCPCS Code

edaravone

Radicava®

J1301

Anemia

Generic Medication Name

Medication Brand Name

HCPCS Code

darbepoetin alfa

Aranesp®

J0881

epoetin alfa

Procrit®/Epogen®

J0885

epoetin alfa-epbx biosimilar (non-ESRD)

Retacrit® (non-ESRD)

Q5106

methoxy polyethylene glycol-epoetin beta (non-ESRD)

Mircera® (non-ESRD)

J0888

Anemia (Dialysis)

Generic Medication Name

Medication Brand Name

HCPCS Code

darbepoetin alfa (ESRD Only)

Aranesp® (ESRD Only)

J0882

epoetin alfa (ESRD Only)

Procrit®/Epogen® (ESRD Only)

Q4081

epoetin alfa-epbx biosimilar (ESRD Only)

Retacrit® (ESRD Only)

Q5105

methoxy polyethylene glycol-epoetin beta (ESRD Only)

Mircera® (ESRD Only)

J0887

Antipruritic (Dialysis)

Generic Medication Name

Medication Brand Name

HCPCS Code

difelikefalin

Korsuva™

J0879

Recent program changes:

  • Korsuva is effective 9/1/2022 as part of this program.

Anti-emetics

Generic Medication Name

Medication Brand Name

HCPCS Code

aprepitant

Cinvanti®

J0185

fosnetupitant/palonosetron

Akynzeo IV®

J1454

granisetron extended-release

Sustol®

J1627

palonosetron

Aloxi®

J2469

rolapitant

Varubi®

J2797

Asthma

Generic Medication Name

Medication Brand Name

HCPCS Code

benralizumab

Fasenra®

J0517

mepolizumab

Nucala®

J2182

omalizumab

Xolair®

J2357

reslizumab

Cinqair®

J2786

tezepelumab-ekko

Tezspire™

J2356

Recent program changes:

  • Tezspire is effective 9/1/2022 as part of this program

Auto-inflammatory Conditions

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

abatacept

Orencia IV®

J0129

anifrolumab-fnia

Saphnelo™

J0491

belimumab

Benlysta IV®

J0490

certolizumab pegol

Cimzia®

J0717

golimumab

Simponi_Aria®

J1602

infliximab

Remicade®

J1745

infliximab-abda

Renflexis®

Q5104

infliximab-axxq

Avsola®

Q5121

infliximab-dyyb

Inflectra®

Q5103

risankizumab-rzaa

Skyrizi® IV

J3590

00074-5015-01

spesolimab-sbzo

Spevigo®

J3590

00597-0035-10

tildrakizumab-asmn

Ilumya®

J3245

tocilizumab

Actemra IV®

J3262

ustekinumab

Stelara®

J3357

ustekinumab

Stelara® IV

J3358

vedolizumab

Entyvio®

J3380

Recent program changes:

  • Skyrizi IV and Spevigo are effective 2/27/2023 as part of this program.
  • Saphnelo is effective 9/1/2022 as part of this program.

Chemotherapy Protectant

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

levoleucovorin calcium

Fusilev®

J0641

levoleucoforin sodium

Khapzory™

J0642

sodium thiosulfate

Pedmark®

J3490

73077-010-01

Recent program changes:

  • Pedmark is effective 2/27/2023 as part of this program.

Duchenne Muscular Dystrophy

Generic Medication Name

Medication Brand Name

HCPCS Code

casimersen

Amondys 45™

J1426

eteplirsen

Exondys™51

J1428

golodirsen

Vyondys 53

J1429

viltolarsen

Viltepso®

J1427

Recent program changes:

  • Amondys 45 is effective 2/1/2022 as part of this program.

Endocrine Disorders

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

corticotropin

H. P. Acthar®

J0800

lanreotide

Lanreotide Acetate

J1932

lanreotide

Somatuline® Depot

J1930

octreotide

Sandostatin® LAR

J2353

pasireotide long acting

Signifor® LAR

J2502

repository corticotrophin injection

Purified Cortrophin® Gel

J3490

62559-860-15

Recent program changes:

  • Purified Cortrophin Gel is effective 2/27/2023 as part of this program.
  • Lanreotide Acetate is effective 1/23/2023 as part of this program.

Enzyme Deficiency

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

agalsidase beta

Fabrazyme®

J0180

alglucosidase alfa

Lumizyme®

J0221

alpha-1-proteinase inhibitor

Aralast NP®

J0256

alpha-1-proteinase inhibitor

Glassia®

J0257

alpha-1-proteinase inhibitor

Prolastin®C

J0256

alpha-1-proteinase inhibitor

Zemaira®

J0256

avalglucosidase alfa-ngpt

Nexviazyme™

J0219

cerliponase alfa

Brineura®

J0567

elapeademase-lvlr

Revcovi™

J3590

57665000201

elosulfase alfa

Vimizim®

J1322

fosdenopterin

Nulibry®

J3490

73129000101

galsulfase

Naglazyme®

J1458

idursulfase

Elaprase®

J1743

imiglucerase

Cerezyme®

J1786

laronidase

Aldurazyme®

J1931

olipudase alfa

XenpozymeTM

J3590

58468-0050-01

sebelipase alfa

Kanuma®

J2840

taliglucerase alfa

Elelyso®

J3060

velaglucerase alfa

Vpriv®

J3385

vestronidase alfa-vjbk

Mepsevii®

J3397

Recent program changes:

  • Xenpozyme is effective 2/27/2023 as part of this program.
  • Nexviazyme, Nulibry and Revcovi are effective 9/1/2022 as part of this program.

Erythropoietic Protoporphyria

Generic Medication Name

Medication Brand Name

HCPCS Code

afamelanotide

Scenesse®

J7352

Hemophilia

Generic Medication Name

Medication Brand Name

HCPCS Code

antihemophiilc factor (recombinant)

Recombinate™

J7192

antihemophilic factor (recombinant)

Kovaltry®

J7211

antihemophilic factor (human)

Koate®-DVI

J7190

antihemophilic factor (human)

Monoclate-P®

J7190

antihemophilic factor (recombinant)

Advate®

J7192

antihemophilic factor (recombinant)

Helixate® FS

J7192

antihemophilic factor (recombinant)

Kogenate®

J7192

antihemophilic factor (recombinant)

Novoeight®

J7182

antihemophilic factor (recombinant)

Nuwiq®

J7209

antihemophilic factor (recombinant)

Xyntha®

J7185

antihemophilic factor (recombinant), glycopegylated-exei

Esperoct®

J7204

antihemophilic factor (recombinant), pegylated

Adynovate®

J7207

antihemophilic factor (recombinant), pegylated-aucl

Jivi®

J7208

antihemophilic factor (recombinant), porcine sequence

Obizur®

J7188

antihemophilic factor (recombinant), single chain

Afstyla®

J7210

antihemophilic factor/von willebrand factor complex (human)

Alphanate®

J7186

antihemophilic factor/von willebrand factor complex (human)

Humate-P®

J7187

antihemophilic factor (human)

Hemofil® M

J7190

antihemophilic factor (recombinant), fc fusion protein

Eloctate®

J7205

anti-inhibitor coagulation complex

Feiba® NF

J7198

anti-inhibitor coagulation complex

Feiba®

J7198

coagulation factor VIIa (recombinant)-jncw

Sevenfact®

J7212

coagulation factor VIIa, recombinant

Novoseven® RT

J7189

coagulation factor IX (Human)

Alphanine® SD

J7193

coagulation factor IX (human)

Mononine®

J7193

coagulation factor IX (recombinant)

Ixinity®

J7195

coagulation factor IX (recombinant)

Rixubis®

J7200

coagulation factor IX (recombinant),
albumin fusion protein

Idelvion®

J7202

coagulation factor IX (recombinant), fc fusion protein

Alprolix®

J7201

coagulation factor IX (recombinant), glycopegylated

Rebinyn®

J7203

coagulation factor VIIa (recombinant)

Novoseven® RT

J7189

coagulation factor X (human)

Coagadex®

J7175

coagulation factor XIII a-subunit (recombinant)

Tretten®

J7181

coagulation factor IX (recombinant)

BeneFIX®

J7195

emicizumab-kxwh

Hemlibra®

J7170

factor IX complex

Profilnine® S/D

J7194

factor VIII concentrate (human)

Corifact®

J7180

von willebrand factor (recombinant)

Vonvendi®

J7179

von willebrand factor/coagulation factor VIII complex

Wilate®

J7183

Hematologic Disorders

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

pegcetacoplan

Empavelli®

J3490

73606001001

plasminogen, human-tvmh

Ryplazim®

J2998

sutimlimab-jome

Enjaymo™

J1302

Recent program changes:

  • Please use HCPCS code J1302 for Enjaymo provided 10/1/2022 and after.
  • Empavelli, Enjaymo and Ryplazim are effective 9/1/2022 as part of this program.

Hereditary Angioedema

Generic Medication Name

Medication Brand Name

HCPCS Code

c1 esterase inhibitor [recombinant]

Ruconest®

J0596

c1 inhibitor (human)

Berinert®

J0597

c1 inhibitor (human)

Cinryze®

J0598

ecallantide

Kalbitor®

J1290

HIV/AIDS

Generic Medication Name

Medication Brand Name

HCPCS Code

cabotegravir

Apretude™

J0739

ibalizumab-uiyk

Trogarzo®

J1746

Recent program changes:

  • Apretude is effective 9/1/2022 as part of this program.

Immunodeficiency

Generic Medication Name

Medication Brand Name

HCPCS Code

emapalumab-lzsg

Gamifant™

J9210

IV immune globulin

Asceniv™

J1554

IV immune globulin

Bivigam®

J1556

IV immune globulin

Carimune® NF

J1566

IV immune globulin

Flebogamma®, Flebogamma® DIF

J1572

IV immune globulin

Gammagard Liquid®

J1569

IV immune globulin

Gammaplex®

J1557

IV immune globulin

Gamunex-C®, Gammaked™

J1561

IV immune globulin

Unclassified IV Immune Globulin

J1599

IV immune globulin

Octagam®

J1568

IV immune globulin

Panzyga®

J1599

IV immune globulin

Privigen®

J1459

subcutaneous immune globulin

Cutaquig®

J1551

subcutaneous immune globulin

Cuvitru®

J1555

subcutaneous immune globulin

Hizentra®

J1559

subcutaneous immune globulin

Hyqvia®

J1575

subcutaneous immune globulin

Xembify®

J1558

Recent program changes:

  • Please use HCPCS code J1551 for Cutaquig provided 7/1/2022 and after.

Inflammatory Conditions

Generic Medication Name

Medication Brand Name

HCPCS Code

eculizumab

Soliris®

J1300

efgartigimod alfa

Vyvgart™

J9332

inebilizumab-cdon

Uplinza®

J1823

pegloticase

Krystexxa®

J2507

ravulizumab-cwz

Ultomiris®

J1303

Recent program changes:

  • Vyvgart is effective 9/1/2022 as part of this program

Mental Health

Generic Medication Name

Medication Brand Name

HCPCS Code

Esketamine

Spravato®

S0013

For Medicare Advantage members, please use the appropriate G (G2082 or G2083) code for esketamine rather than S0013.

Metabolic Conditions

Generic Medication Name

Medication Brand Name

HCPCS Code

burosumab-twza

Crysvita®

J0584

evinacumab-dgnb

Evkeeza™

J1305

inclisiran

Leqvio®

J1306

Recent program changes:

  • Leqvio is effective 9/1/2022 as part of this program.
  • Evkeeza is effective 2/1/2022 as part of this program

Multiple Sclerosis

Generic Medication Name

Medication Brand Name

HCPCS Code

alemtuzumab

Lemtrada®

J0202

natalizumab

Tysabri®

J2323

ocrelizumab

Ocrevus®

J2350

Migraine

Generic Medication Name

Medication Brand Name

HCPCS Code

eptinezumab-jjmr

Vyepti™

J3032

Myelodysplastic Syndrome

Generic Medication Name

Medication Brand Name

HCPCS Code

luspatercept-aamt

Reblozyl®

J0896

Neutropenia

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

eflapegrastim-xnst

Rolvedon™

J3590

76961-0101-01

filgrastim

Neupogen®

J1442

filgrastim-aafi

Nivestym®

Q5110

fligrastim-ayow

Releuko®

Q5125

pegfilgrastim-fpgk

Stimufend®

J3590

65219-371-10

filgrastim-sndz

Zarxio®

Q5101

pegfilgrastim

Neulasta®

J2506

pegfilgrastim-apgf

Nyvepria™

Q5122

pegfilgrastim-bmez

Ziextenzo®

Q5120

pegfilgrastim-cbqv

Udenyca®

Q5111

pegfilgrastim-jmbd

Fulphila®

Q5108

pegfilgratim-pbbk

Fylnetra®

J3590

70121-1627-01

sargramostim

Leukine®

J2820

tbo-filgrastim

Granix®

J1447

Recent program changes:

  • Rolvedon and Stimufend are effective 2/27/2023 as part of this program.
  • Fylnetra is effective 1/23/2023 as part of this program.
  • Please use HCPCS code Q5125 for Releuko provided 10/1/2022 and after.
  • Releuko is effective 9/1/2022 as part of this program

Ocular Conditions

Generic Medication Name

Medication Brand Name

HCPCS Code

faricimab-svoa

Vabysmo®

J2777

ranibizumab

Susvimo™

J2779

Recent program changes:

  • Please use HCPCS code J2777 for Vabysmo provided 10/1/2022 and after.
  • Susvimo and Vabysmo are effective 9/1/2022 as part of this program.

Oncology

Generic Medication Name

Medication Brand Name

HCPCS Code

NDC

ado-trastuzumab emtansine

Kadcyla®

J9354

aldesleukin

Proleukin®

J9015

amivantamab-vmjw

Rybrevant™

J9061

asparaginase

Erwinaze®

J9019

Asparaginase erwinia chrysanthemi (recombinant)-rywn

Rylaz™

J9021

atezolizumab

Tecentriq®

J9022

avelumab

Bavencio®

J9023

belantamab mafodotin-blmf

Blenrep™

J9037

belinostat

Beleodaq®

J9032

bendamustine

Bendeka®

J9034

bendamustine

Treanda®

J9033

bendamustine hydrochloride

Belrapzo®

J9036

bevacizumab (cancer dxs only)

Avastin® (Cancer Dxs Only)

J9035

bevacizumab-adcd

Vegzelma

J9999

32228-011-01
32228-011-02
32228-011-03
32228-011-04

bevacizumab-awwb

Mvasi™

Q5107

bevacizumab-awwb

Zirabev®

Q5118

bevacizumab-maly

Alymsys®

J9999
C9142

70121-1754-1
70121-1755-1

blinatumomab

Blincyto®

J9039

bortezomib

Bortezomib

J9044

bortezomib

Velcade®

J9041

brentuximab vedotin

Adcetris®

J9042

cabazitaxel

Jevtana®

J9043

calaspargase pegol-mknl

Asparlas®

J9118

carfilzomib

Kyprolis®

J9047

cemiplimab-rwlc

Libtayo®

J9119

cetuximab

Erbitux®

J9055

copanlisib

Aliqopa™

J9057

daratumumab

Darzalex®

J9145

daratumumab and hyaluronidase-fihj

Darzalex Faspro™

J9144

daunorubicin; cytarabine liposomal

Vyxeos®

J9153

dostarlimab-gxly

Jemperli

J9272

durvalumab

Imfinzi®

J9173

elotuzumab

Empliciti®

J9176

enfortumab vedotin-ejfv

Padcev®

J9177

fam-trastuzumab deruxtecan-nxki

Enhertu®

J9358

gemcitabine

Infugem™

J9198

gemtuzumab ozogamicin

Mylotarg®

J9203

inotuzumab ozogamicin

Besponsa®

J9229

ipilimumab

Yervoy®

J9228

irinotecan liposome

Onivyde®

J9205

isatuximab-irfc

Sarclisa®

J9227

ixabepilone

Ixempra®

J9207

loncastuximab tesirine

Zynlonta®

J9359

lurbinectedin

Zepzelca™

J9223

margetuximab-cmkb

Margenza™

J9353

melphalan

Evomela®

J9246

melphalan flufenamide

Pepaxto®

J9247

mitomycin

Jelmyto®

J9281

mogamulizumab-kpkc

Poteligeo®

J9204

moxetumomab pasudotox-tdfk

Lumoxiti®

J9313

naxitamab-gqgk

Danyelza®

J9348

necitumumab

Portrazza®

J9295

nivolumab

Opdivo®

J9299

nivolumab/relatlimab-rmbw

Opdualag™

J9298

obinutuzumab

Gazyva®

J9301

ofatumumab

Arzerra®

J9302

olaratumab

Lartruvo®

J9285

omacetaxine

Synribo®

J9262

paclitaxel protein-bound

Abraxane®

J9264

panitumumab

Vectibix®

J9303

pegaspargase

Oncaspar®

J9266

pembrolizumab

Keytruda®

J9271

pertuzumab

Perjeta®

J9306

pertruzumab, trastuzumab, and hyaluronidase-zzxf

Phesgo™

J9316

plerixafor

Mozobil®

J2562

polatuzumab vedotin-piqq

Polivy®

J9309

pralatrexate

Folotyn®

J9307

ramucirumab

Cyramza®

J9308

rituximab

Rituxan®

J9312

rituximab-arrx

Riabni™

Q5123

rituximab-abbs

Truxima®

Q5115

rituximab-pvvr

Ruxience®

Q5119

rituximab/hyaluronidase

Rituxan Hycela®

J9311

romidepsin, lypholized

Istodax®

J9319

romidepsin, non-lypholized

Available as generic medication only

J9318

sacituzumab govitecan-hziy

Trodelvy®

J9317

siltuximab

Sylvant®

J2860

sipuleucel-T

Provenge®

Q2043

sirolimus-albumin-bound

Fyarro™

J9331

tafasitamab-cxix

Monjuvi®

J9349

tagraxofusp-erzs

Elzonris®

J9269

talimogene laherparepvec

Imlygic®

J9325

tebentafusp-tebn

Kimmtrak®

J9274

tisotumab vedotin-tftv

Tivdak®

J9273

trabectedin

Yondelis®

J9352

trastuzumab

Herceptin®

J9355

trastuzumab-anns

Kanjinti™

Q5117

trastuzumab-dkst

Ogiviri®

Q5114

trastuzumab-dttb

Ontruzant®

Q5112

trastuzumab-hyaluronidase-oysk

Herceptin Hylecta™

J9356

trastuzumab-pkrb

Herzuma®

Q5113

trastuzumab-qyyp

Trazimera®

Q5116

trilaciclib

Cosela™

J1448

vincristine liposomal

Marqibo®

J9371

ziv-aflibercept

Zaltrap®

J9400

Recent program changes:

  • Vegzelma is effective 2/27/2023 as part of this program.
  • Alymsys and Opdualag are effective 1/23/2023 as part of this program.
  • Please use HCPCS code J9274 for Kimmtrak provided 10/1/2022 and after.
  • Fyarro, Kimmtrak, Tivdak and Zynlonta are effective 9/1/2022 as part of this program.
  • Rylaze, Rybrevant and Jemperli are effective 4/1/2022 as part of this program.

Osteoarthritis

Generic Medication Name

Medication Brand Name

HCPCS Code

hyaluronan or derivative

Durolane®

J7318

hyaluronan or derivative

Gel-One®

J7326

hyaluronan or derivative

Gelsyn-3®

J7328

hyaluronan or derivative

Genvisc 850®

J7320

hyaluronan or derivative

Hyalgan®

J7321

hyaluronan or derivative

Hymovis®

J7322

hyaluronan or derivative

Supartz®

J7321

hyaluronan or derivative

Synojoynt™

J7331

hyaluronan or derivative

TriVisc®

J7329

hyaluronan or derivative

Visco-3™

J7321

sodium hyaluronate

Triluron®

J7332

Osteoporosis

Generic Medication Name

Medication Brand Name

HCPCS Code

denosumab

Prolia®, Xgeva®

J0897

romosozumab-aqqg

Evenity®

J3111

Primary Hyperoxaluria

Generic Medication Name

Medication Brand Name

HCPCS Code

lumasiran

Oxlumo™

J0224

Sickle Cell Disease

Generic Medication Name

Medication Brand Name

HCPCS Code

crizanlizumab-tmca

Adakveo®

J0791

Spinal Muscular Atrophy

Generic Medication Name

Medication Brand Name

HCPCS Code

nusinersen

Spinraza®

J2326

Thrombocytopenia

Generic Medication Name

Medication Brand Name

HCPCS Code

romiplostim

Nplate®

J2796

Thyroid Eye Disease

Generic Medication Name

Medication Brand Name

HCPCS Code

teprotumumab-trbw

Tepezza®

J3241