New drugs added to Medical Drug Prior Authorization Program

Starting April 1, 2017, Exondys 51™ (eteplirsen), Remicade^® (infliximab) and Inflectra™ (infliximab-dyyb) will be added to the list of drugs that require a medical drug prior authorization. The Medical Drug Prior Authorization Program does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Drug name	HCPCS code
Exondys 51™	J3490/J3590
Inflectra™	Q5102
Remicade^®	J1745

The list below includes the three newly added drugs, along with all other medications that are part of the Medical Drug Prior Authorization Program.

Drug name	Drug name	Drug name	Drug name
Actemra^®	Depo^®-Testosterone	Immune globulin	Prolia^®
Acthar^® gel	Dysport^®	Inflectra™	Remicade^®
Adagen^®	Elaprase^®	Kalbitor^®	Ruconest^®
Aldurazyme^®	Elelyso™	Kanuma™	Signifor^® LAR
Aralast NP™	Entyvio™	Krystexxa^®	Simponi Aria^®
Aveed^®	Exondys 51™	Lemtrada™	Soliris^®
Benlysta^®	Fabrazyme^®	Lumizyme^®	Stelara^®
Berinert^®	Firazyr^®	Makena^®	Stelara IV^®
Bivigam™	Flebogamma^® DIF	Myobloc^®	Synagis^®
Botox^®	Gammagard Liquid^®	Myozyme^®	Testopel^®
Carimune^® NF	Gammagard^® S/D	Naglazyme^®	Tysabri^®
Cerezyme^®	Gammaked^®	Nplate^®	Vimizim™
Cimzia^®	Gammaplex^®	Nucala^®	Vpriv^®
Cinqair^®	Gamunex^®	Octagam^®	Xeomin^®
Cinryze^®	Glassia™	Orencia^®	Xgeva^®
Cosentyx™	Hizentra^®	Privigen^®	Xiaflex^®
Cuvitru^®	HyQvia^®	Probuphine^®	Xolair^®
Delatestryl^®	Ilaris^®	Prolastin^®-C

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.