Skip to Content

Provider Manual

Medical pharmacy prior authorization

Last Updated on November 13, 2018

Security Health Plan of Wisconsin, Inc., is partnering with Magellan Rx Management (Magellan Rx) to manage a new process for reviewing and approving certain specialty medications. These changes went into effect   Nov. 1, 2017. To review a list of frequently asked questions, click here.

For a list of medications that require prior authorization, click here. For a list of medications that may require post service claim edits, click here.

Prior authorization list

Below is a list of medications with their corresponding Healthcare Common Procedure Coding System (HCPCS) codes that require prior authorization (PA) for dates of service on or after Nov. 1, 2017. In addition, any administration fee for a drug that has been denied will also be denied. All medications that require prior authorization will also be subject to post-service claim edits. See the ‘Post service claim edit’ section below for additional details on post-service claim edits. To view prior authorization criteria or to submit an authorization click the ‘Submit a prior authorization’ button below.

Submit a prior authorization

Prior Authorization List

HCPCS

Brand Name

Generic Name

J0129 Orencia® abatacept
J9354 Kadcyla® ado-trastuzumab emtansine
J0180 Fabrazyme® - effective 6/1/18 agalsidase beta
J0202 Lemtrada® alemtuzumab
J0221 Lumizyme alglucosidase alfa - effective 10/1/2018
J9022 Tecentriq® atezolizumab - effective 10/1/2018
J9023 Bavencio® avelumab - effective 10/1/2018
J0490 Benlysta® belimumab
J9032 Beleodaq® belinostat
J9034 Bendeka® bendamustine
J9033 Treanda® bendamustine
J9035 Avastin® (Oncology indications only) bevacizumab
J9039 Blincyto® blinatumomab
J9042 Adcetris® brentuximab vedotin
J0596 Ruconest® C1 Esterase Inhibitor [recombinant]
J0597 Berinert® C1 Inhibitor
J0598 Cinryze® C1 Inhibitor
J9043 Jevtana® cabazitaxel
J9047 Kyprolis® carfilzomib
J0717 Cimzia® certolizumab pegol
J9055 Erbitux® cetuximab
J0800 Acthar-HP® corticotropin
J9145 Darzalex® daratumumab
J0881 Aranesp® darbepoetin
J0897 Prolia® denosumab
J0897 Xgeva® denosumab
J1290 Kalbitor® ecallantide
J1300 Soliris® eculizumab
J9176 Empliciti® elotuzumab
J0885 Procrit®/Epogen® epoetin alfa
J9179 Halaven® eribulin
J1428 Eteplirsen EXONDYS 51® - effective 1/1/2019
J1442 Neupogen® filgrastim
J1458 Naglazyme® galsulfase - effective 10/1/2018
J1602 Simponi® ARIA golimumab
J1627 Sustol® granisetron extended release - effective 10/1/2018
J1744 Firazyr® icatibant
J1743 Elaprase® idursulfase - effective 10/1/2018
J1786 Cerezyme® imiglucerase - effective 10/1/2018
J1566 Gammagard S/D® Immune Globulin
J1555 Cuvitru® immune globulin - effective 10/1/2018
J1745 Remicade® infliximab
Q5104 Renflexis® infliximab-abda
Q5103 Inflectra® infliximab-dyyb
J1556 Bivigam® intravenous immune globulin
J1566 Carimune NF® intravenous immune globulin
J1572 Flebogamma® intravenous immune globulin
J1569 Gammagard® Liquid intravenous immune globulin
J1561 Gammaked® intravenous immune globulin
J1557 Gammaplex® intravenous immune globulin
J1561 Gamunex-C® intravenous immune globulin
J1599 Intravenous Immune Globulin intravenous immune globulin
J1568 Octagam® intravenous immune globulin
J1459 Privigen® intravenous immune globulin
J9228 Yervoy® ipilimumab
J9205 Onivyde® irinotecan liposome
J1931 Aldurazyme® laronidase - effective 10/1/2018
J0641 Fusilev® levoleucovorin calcium
J2182 Nucala® mepolizumab
J2323 Tysabri® natalizumab
J9295 Portrazza® necitumumab
J9299 Opdivo® nivolumab
J9301 Gazyva® obinutuzumab
J2350 Ocrevus®- effective 6/1/18 ocrelizumab
J2353 Sandostatin® LAR octreotide
J9302 Arzerra® ofatumumab
J9262 Synribo® omacetaxine
J2357 Xolair® omalizumab
J9264 Abraxane® paclitaxel
J2469 Aloxi® palonosetron
J9303 Vectibix ® panitumumab
90378 Synagis® pavilzumab
J9266 Oncaspar pegaspargase - effective 10/1/2018
J2505 Neulasta® pegfilgrastim
J2507 Krystexxa® pegloticase
J9271 Keytruda® pembrolizumab
J9305 Alimta® pemetrexed
J9306 Perjeta® pertuzumab
J2562 Mozobil® Plerixafor - effective 1/1/2019
J9308 Cyramza® ramucirumab
J3285 Treprostinil REMODULIN® - effective 1/1/2019
J2786 Cinqair® reslizumab
J9310 Rituxan® rituximab
J2796 Nplate® romiplostim
J2860 Sylvant® siltuximab
Q2043 Provenge® sipuleucel-t
J2326 Nusinersen SPINRAZA® - effective 1/1/2019
J1559 Hizentra® subcutaneous immune globulin
J1575 HyQvia® subcutaneous immune globulin
J3060 Elelyso® taliglucerase alfa - effective 10/1/2018
J3262 Actemra® tocilizumab
J9352 Yondelis® trabectedin
J9355 Herceptin® trastuzumab
J3358 Stelara® IV ustekinumab
J3357 Stelara® SQ ustekinumab
J3380 Entyvio® vedolizumab
J9400 Zaltrap® vedolizumab
J3385 Vpriv® velaglucerase alfa - effective 10/1/2018
J1325 Epoprostenol VELETRI® - effective 1/1/2019
J9371 Marqibo® vincristine Liposomal

Post service claim edits

Below is a list of medications with their corresponding Healthcare Common Procedure Coding System (HCPCS) codes that will have post-service claim edits applied for dates of service on or after Nov. 1, 2017. For more information on the Magellan Post Service Claim Edits Program and how it may affect your payment, click here.     As a reminder some of these medications may also require prior authorization. Refer to the table above for a list of medications that also require authorization. 

PLEASE NOTE: For the following policies, Security Health Plan applies pre-payment, post-service claim edits using diagnosis and maximum unit criteria. Prior authorization criteria do not apply for these policies.

Post-Service Claim Edit List

HCPCS

Brand name

Generic name

J9264 Abraxane® paclitaxel
J3262 Actemra® tocilizumab
J0800 Acthar HP® corticotropin
J9042 Adcetris® brentuximab vedotin
J1931 Aldurazyme® laronidase - effective 10/1/2018
J9305 Alimta® pemetrexed
J2469 Aloxi® palonosetron
J0881 Aranesp® darbepoetin
J9302 Arzerra® ofatumumab
J9035 Avastin® (Oncology indications only) bevacizumab
J9023 Bavencio® avelumab - effective 10/1/2018
J9032 Beleodaq® belinostat
J9034 Bendeka® bendamustine
J0490 Benlysta® belimumab
J0597 Berinert® C1 Inhibitor
J1556 Bivigam® intravenous immune globulin
J9039 Blincyto® blinatumomab
J0585 Botox® onabotulinumtoxinA
J1566 Carimune NF® intravenous immune globulin
J1786 Cerezyme® imiglucerase - effective 10/1/2018
J0717 Cimzia® certolizumab pegol
J2786 Cinqair® reslizumab
J0598 Cinryze® C1 Inhibitor
J1555 Cuvitru® immune globulin - effective 10/1/2018
J9308 Cyramza® ramucirumab
J0894 Dacogen Injection, decitabine - effective 10/1/2018
J9145 Darzalex® daratumumab
J0586 Dysport® abobotulinumtoxinA
J1743 Elaprase® idursulfase - effective 10/1/2018
J3060 Elelyso® taliglucerase alfa - effective 10/1/2018
J9217 Eligard® leuprolide acetate (for depot suspension)
J1453 Emend® fosaprepitant
J9176 Empliciti® elotuzumab
J3380 Entyvio® vedolizumab
J1325 Epoprostenol VELETRI® - effective 1/1/2019
J9055 Erbitux® cetuximab
J1428 Eteplirsen EXONDYS 51®- effective 1/1/2019
J7323 Euflexxa® hyaluronan or derivative
J0178 Eylea® aflibercept
J0180 Fabrazyme®- effective 6/1/18 agalsidase beta
J9395 Faslodex® fulvestrant
J1744 Firazyr® icatibant
J1572 Flebogamma® intravenous immune globulin
Q5108 Fulphila® pegefilgrastim-jmdb - effective 10/1/2018
J0641 Fusilev® levoleucovorin calcium
J1569 Gammagard® Liquid intravenous immune globulin
J1566 Gammagard® S/D immune globulin
J1561 Gammaked® intravenous immune globulin
J1557 Gammaplex® intravenous immune globulin
J1561 Gamunex-C® intravenous immune globulin
J9301 Gazyva® obinutuzumab
J7326 Gel-One® hyaluronan or derivative
J7328 GelSyn-3® hyaluronan or derivative
J9201 Gemzar® gemcitabine
J7320 GenVisc ® hyaluronan or derivative
J1447 Granix® tbo-filgrastim
J9179 Halaven® eribulin
J9355 Herceptin® trastuzumab
J1559 Hizentra® subcutaneous immune globulin
J7321 Hyalgan® hyaluronan or derivative
J7322 Hymovis® hyaluronan or derivative
J1575 HyQvia® subcutaneous immune globulin
Q5103 Inflectra® infliximab-dyyb
J1599 intravenous immune globulin intravenous immune globulin
J9043 Jevtana® cabazitaxel
J9354 Kadcyla® trastuzumab emtansine
J1290 Kalbitor® ecallantide
J9271 Keytruda® pembrolizumab
J2507 Krystexxa® pegloticase
J9047 Kyprolis® carfilzomib
J0202 Lemtrada® alemtuzumab
J2820 Leukine® sargramostim
J2778 Lucentis® ranibizumab
J0221 Lumizyme alglucosidase alfa - effective 10/1/2018
J1950 Lupron® Depot leuprolide acetate (for depot suspension)
J9217 Lupron® Depot leuprolide acetate (for depot suspension)
J1950 Lupron® Depot Ped leuprolide acetate (for depot suspension)
J2503 Macugen® pegaptanib Sodium
J9371 Marqibo® vincristine liposomal
J7327 Monovisc® hyaluronan or derivative
J2562 Mozobil® Plerixafor - effective 1/1/2019
J0587 Myobloc® rimabotulinumtoxinB
J1458 Naglazyme® galsulfase - effective 10/1/2018
J2505 Neulasta® pegfilgrastim
J1442 Neupogen® filgrastim
J2796 NPLATE® romiplostim
J2182 Nucala® mepolizumab
J2326 Nusinersen SPINRAZA® - effective 1/1/2019
J2350 Ocrevus- effective 6/1/18 ocrelizumab
J1568 Octagam® intravenous immune globulin
J9266 Oncaspar pegaspargase - effective 10/1/2018
J9205 Onivyde® irinotecan liposome
J9299 Opdivo® nivolumab
J0129 Orencia® abatacept
J7324 Orthovisc® hyaluronan or derivative
J9306 Perjeta® pertuzumab
J9295 Portrazza® necitumumab
J1459 Privigen® intravenous immune globulin
J0885 Procrit®/Epogen® epoetin alfa
J0897 Prolia® denosumab
Q2043 Provenge® sipuleucel-t
J1745 Remicade® infliximab
Q5102 Renflexis® infliximab-abda
J0885 Retacrit epoetin zeta - effective 10/1/2018
J9310 Rituxan® rituximab
J0596 Ruconest® C1 Esterase Inhibitor [recombinant]
J2353 Sandostatin® LAR octreotide
J1602 Simponi® Aria golimumab
J1300 Soliris® eculizumab
J3358 Stelara® IV ustekinumab
J3357 Stelara® SQ ustekinumab
J7321 Supartz® hyaluronan or derivative
J1627 Sustol® granisetron extended release - effective 10/1/2018
J2860 Sylvant® siltuximab
90378 Synagis® pavilzumab
J9262 Synribo® omacetaxine
J7325 Synvisc® hyaluronan or derivative
J7325 Synvisc-One® hyaluronan or derivative
J9022 Tecentriq® atezolizumab - effective 10/1/2018
J9033 Treanda® bendamustine
J3315 Trelstar® Depot triptorelin Pamoate
J3285 Treprostinil REMODULIN® - effective 1/1/2019
J2323 Tysabri® natalizumab
J9225 Vantas® histrelin acetate
J9303 Vectibix ® panitumumab
J9041 Velcade® bortezomib
J3385 Vpriv® velaglucerase alfa
J0588 Xeomin® incobutulinumtoxinA
J0897 Xgeva® denosumab
J2357 Xolair® omalizumab
J9228 Yervoy® ipilimumab
J9352 Yondelis® trabectedin
J9400 Zaltrap® aflibercept
Q5101 Zarxio® filgrastim-sndz
J9202 Zoladex® goserelin Acetate Implant