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Políticas Médicas

Nuestras políticas médicas definen la manera en que MMM Holdings LLC y sus subsidiarias identifican y evalúan solicitudes de servicios específicos mediante la aplicación de guías clínicas. Las políticas se adhieren a las guías de Determinaciones de Cobertura Nacional y Local (NCD o LCD) y/o los Artículos definidos por los Centros de Medicare y Medicaid (CMS) y/o cualquier otro criterio clínico. Las políticas reflejan la investigación científica actual y los estándares de guías clínicas basadas en esta evidencia.

Políticas - Rx Parte B

Esta sección contiene los criterios clínicos para los medicamentos y terapias inyectables, en infusión o implantados cubiertos por el beneficio médico, que están sujetos a autorización previa. Los criterios clínicos se desarrollan para ayudar a guiar el uso clínicamente apropiado de medicamentos y terapias y son revisados y aprobados por el Comité de Farmacia y Terapéutica (P&T). El Comité de Farmacia y Terapéutica es un comité independiente y externo que incluye médicos practicantes, farmacéuticos y clínicos de los principales centros médicos académicos y prácticas clínicas con experiencia en medicina basada en la evidencia.

Brand Name Generic Name HCPCS Code Policy Name Policy Number
Actemra Tocilizumab J3262 Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) MP-RX-FP-59-23
Advate Antihemophilic Factor (Rcmb) Plasma/Albumin Free (rAHF-PFM) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Adynovate  Antihemophilic Factor (Recombinant) Pegylated J7207 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Afstyla Antihemophilic Factor (Recombinant) Single Chain J7210 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Aimovig Erenumab C9399; J3490; J3590 CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) MP-RX-FP-17-23
Ajovy Fremanezumab-vfrm J3031 CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) MP-RX-FP-17-23
Akynzeo Netupitant, palonosetron J8655 Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) LCD: L33827 - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
Tyvaso Treprostinil J7686 Nebulizers LCD - Nebulizers (L33370)
Alphanate  Antihemophilic viii/vwf comp J7186 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
AlphaNine Coagulation Factor IX J7193 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Alprolix Coagulation Factor IX (Recomb) Fc Fusion Protein (rFIXFc) J7201 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Altuviio Factor VIII/von Willebrand factor complex, recombinant J7214 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Anktiva Nogapendekin alfa inbakicept-pmln J9999 Anktiva_PartB_MedPol_2024 MP-RX-FP-154-24
Aralast Alpha1-Proteinase Inhibitor (Human) J0256 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Aranesp (Albumin Free) Darbepoetin alfa, non-esrd J0881 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Aranesp (Albumin Free) Darbepoetin alfa, esrd use J0882 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Atgam Lymphocyte Immune Globulin,Anti-Thymocyte Globulin (Equine) J7504 Antithymocyte Globulin Equine, (Atgam) MP-RX-FP-08-24
Avastin Bevacizumab J9035 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) MP-RX-FP-13-23
Avsola Infliximab-axxq Q5121 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
BeneFix Coagulation Factor IX (Recombinant) J7195 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Benlysta Belimumab J0490 Benlysta (belimumab) MP-RX-FP-11-23
Berinert C1 Esterase Inhibitor (Human) J0597 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Bonsity Teriparatide J3110 Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) MP-RX-FP-37-23
Botox OnabotulinumtoxinA J0585 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Cabenuva Cabotegravir & Rilpivirine J0741 Cabotegravir extended-release; rilpivirine extended-release (Cabenuva) MP-RX-FP-16-23
Cerezyme Imiglucerase J1786 Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) MP-RX-FP-29-23
Cinqair Reslizumab J2786 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Cinryze C1 Esterase Inhibitor (Human) J0598 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Coagadex Coagulation Factor X (Human) J7175 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Corifact Factor XIII Concentrate (Human) J7180 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Tretten Coagulation Factor XIII A-Subunit (Recombinant) J7181 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Darzalex Daratumumab J9145 Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) MP-RX-FP-21-23
Darzalex Faspro Daratumumab and hyaluronidase-fijh J9144 Daratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) MP-RX-FP-21-23
Dodex Cyanocobalamin J3420 Vitamin B12 Injections LCD - Vitamin B12 Injections (L33967) (cms.gov)
Duopa Carbidopa-Levodopa J7340 Carbidopa and levodopa enteral suspension (Duopa) MP-RX-FP-22-23
Dupixent Dupilumab C9399; J3490; J3590 Dupilumab (Dupixent) MP-RX-FP-23-23
Durolane Sodium Hyaluronate (Viscosupplement) J7318 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Supartz Hyaluronan J7321 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Visco-3 Hyaluronan J7321 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Durysta Bimatoprost J7351 Durysta [Bimatoprost Implant] MP-RX-FP-24-23
Dysport AbobotulinumtoxinA J0586 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Egrifta Tesamorelin Acetate J3490; J3590 Tesamorelin (Egrifta) MP-RX-FP-25-23
Elelyso Taliglucerase Alfa J3060 Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) MP-RX-FP-29-23
Eloctate Antihemophilic Factor (Recombinant) Fc Fusion Protein(BDD-rFVIIIFc) J7205 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Emend Aprepitant, oral J8501 Oral antiemetic drugs: Aprepitant MP-RX-FP-07-23
Emgality Galcanezumab C9399; J3490; J3590 CGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) MP-RX-FP-17-23
Enhertu fam-trastuzumab deruxtecan-nxk J9358 Trastuzumab – Trastuzumab Biologics MP-RX-FP-161-24
Entyvio Vedolizumab J3380 Vedolizumab (Entyvio) MP-RX-FP-28-23
Epogen Epoetin alfa, esrd Q4081 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Epogen Epoetin alfa, non-esrd J0885 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Esperoct  Antihemophilic Factor (Recombinant) Glycopegylated-exei J7204 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Euflexxa Sodium Hyaluronate (Viscosupplement) J7323 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Evenity Romosozumab-aqqg J3111 Romosozumab (Evenity) MP-RX-FP-32-23
Fasenra Benralizumab J0517 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Fasenra Pen Benralizumab J0517 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Feiba NF Antiinhibitor Coagulant Complex J7198 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Feraheme Ferumoxytol Q0138 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Ferrlecit Sodium ferric gluconate/sucrose complex J2916 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Fibryga Fibrinogen Concentrate (Human) J7177 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Firazyr Icatibant Acetate J1744 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Forteo Teriparatide (Recombinant) J3110 Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) MP-RX-FP-37-23
Fulphila Pegfilgrastim-jmdb Q5108 Colony Stimulating Factors MP-RX-FP-18-23
Gammagard Gammagard liquid injection J1569 Immunoglobulins MP-RX-FP-40-23
Gammagard S/D Immune Globulin (Human) IV J1566 Immunoglobulins MP-RX-FP-40-23
Gamunex Immune Globulin (Human) IV J1561 Immunoglobulins MP-RX-FP-40-23
Gazyva Obinutuzumab J9301 Obinutuzumab (Gazyva®) MP-RX-FP-33-23
Gel-One Cross-Linked Hyaluronate J7326 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Gel-Syn Hyaluronan or derivative, for intra-articular injection J7328 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
GenVisc 850 Sodium Hyaluronate (Viscosupplement) J7320 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Glassia Alpha1-Proteinase Inhibitor (Human) J0257 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Granix Tbo-Filgrastim J1447 Colony Stimulating Factors MP-RX-FP-18-23
Haegarda C1 Esterase Inhibitor (Human) J0599 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Halaven Eribulin J9179 Eribulin mesylate (Halaven®) MP-RX-FP-35-23
Hemlibra  Emicizumab-kxwh J7170 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Hemofil-M Antihemophilic Factor (Human) J7190 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Herceptin Trastuzumab J9355 Trastuzumab – Trastuzumab Biologics MP-RX-FP-161-24
Herceptin Hylecta Trastuzumab, and hyaluronidase-oysk J9356 Trastuzumab – Trastuzumab Biologics MP-RX-FP-161-24
Humalog®, Humulin®, Novolin®, Novolog®, Insulin Lispro®, Apidra Solostar® Insulin Lispro or Aspart for insulin pump use J1817, S5550, S5551 Infusion Pumps NCD: 280.14 - Infusion Pumps
Humate-P Antihemophilic Factor/von Willebrand Factor Complex (Human) J7187 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Hyalgan Sodium Hyaluronate (Viscosupplement) J7321 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Hymovis Hyaluronan J7322 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Hyqvia Immune Globulin (Human)-Hyaluronidase (Human Recombinant) J1575 Immunoglobulins MP-RX-FP-40-23
Idelvion Coagulation Factor IX Recomb Albumin Fusion Protein (rIX-FP) J7202 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Ilumya Tildrakizumab-asmn J3245 Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] MP-RX-FP-61-23
Iluvien Fluocinolone acetonide intravitreal implant J7313 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
Infed Iron dextran J1750 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Inflectra Infliximab-dyyb Q5103 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Infliximab Infliximab J1745 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Injectafer Ferric carboxymaltose J1439 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
ISTODAX Romidepsin J9319 Romidepsin (Istodax®) MP-RX-FP-45-23
Ixifi Infliximab-qbtx Q5109 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Ixinity Coagulation Factor IX (Recombinant) J7195 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Jivi Antihemophilic Factor (Recombinant) PEGylated-aucl (BDD-rFVIII PEG-aucl) J7208 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Kalbitor Ecallantide J1290 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Kevzara Sarilumab C9399; J3490; J3590 Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara) MP-RX-FP-59-23
Keytruda Pembrolizumab J9271 Pembrolizumab (Keytruda®) MP-RX-FP-49-23
Koate Antihemophilic Factor (Human) J7190 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Koate-DVI Antihemophilic Factor (Human) J7190 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Kogenate FS Antihemophilic Factor (Recombinant) (rFVIII) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Kovaltry Antihemophilic Factor (Recombinant) Plasma/Albumin Free (rAHF-PFM) J7211 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Krystexxa Pegloticase J2507 Krystexxa (pegloticase) MP-RX-FP-50-23
Lanreotide Lanreotide (cipla) J1932 Lanreotide (Somatuline Depot) MP-RX-FP-83-23
Lemtrada Alemtuzumab J0202 Alemtuzumab [Lemtrada] MP-RX-FP-52-23
Leqvio Inclisiran, 1 mg J1306 Inclisiran [Leqvio] MP-RX-FP-53-23
Libtayo cemiplimab-rwlc J9119 Cemiplimab-rwlc (Libtayo®) MP-RX-FP-54-23
Monoferric Ferric derisomaltose J1437 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Monovisc Hyaluronan J7327 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Mvasi Bevacizumab Q5107 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) MP-RX-FP-13-23
MYCOPHENOLATE MOFETIL ORAL Mycophenolate mofetil J7517 Immunosuppressive Drugs LCD - Immunosuppressive Drugs (L33824) (cms.gov)
MYCOPHENOLATE SODIUM Mycophenolic acid J7518 Immunosuppressive Drugs LCD - Immunosuppressive Drugs (L33824) (cms.gov)
Myobloc RimabotulinumtoxinB J0587 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Leukine Sargramostim J2820 Colony Stimulating Factors MP-RX-FP-18-23
Neulasta Pegfilgrastim J2506 Colony Stimulating Factors MP-RX-FP-18-23
Neupogen Filgrastim J1442 Colony Stimulating Factors MP-RX-FP-18-23
Nivestym Filgrastim-aafi Q5110 Colony Stimulating Factors MP-RX-FP-18-23
Novoeight  Antihemophilic Factor VIII (Recombinant) BD Truncated (BD trunc-rFVIII) J7182 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
NovoSeven RT Coagulation Factor VIIa (Recombinant) J7189 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Nplate Romiplostim J2796 Romiplostim (Nplate) MP-RX-FP-63-23
Nucala Mepolizumab J2182 Monoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)] MP-RX-FP-58-23
Nuwiq Antihemophilic Factor (Rcmb) Simoctocog alfa(BDD-rFVIII,sim) J7209 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Nyvepria Pegfilgrastim-apgf Q5122 Colony Stimulating Factors MP-RX-FP-18-23
Rolvedon Eflapegrastim-xnst J1449 Colony Stimulating Factors MP-RX-FP-18-23
Obizur Antihemophilic Factor (Recombinant Porcine) (rpFVIII) J7188 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Ocrevus Zunovo Ocrelizumab hyaluronidase J3590 Ocrelizumab [Ocrevus®], Ocrelizumab/hyaluronidase-ocsq [Ocrevus Zunovo®] MP-RX-FP-64-23
Ocrevus Ocrelizumab J2350 Ocrelizumab [Ocrevus®], Ocrelizumab/hyaluronidase-ocsq [Ocrevus Zunovo®] MP-RX-FP-64-23
Orencia Abatacept J0129 Orencia (abatacept) MP-RX-FP-68-23
Orthovisc Hyaluronan J7324 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Ozurdex Dexamethasone intravitreal implant J7312 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
Padcev Enfortumab J9177 Enfortumab vedotin-ejfv (Padcev®) MP-RX-FP-70-23
Panzyga Ivig non-lyophilized, nos J1599 Immunoglobulins MP-RX-FP-40-23
Privigen Inj ivig privigen 500 mg J1459 Immunoglobulins MP-RX-FP-40-23
Procrit Epoetin alfa, non-esrd J0885 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Procrit Epoetin alfa, 100 units esrd Q4081 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Profilnine Factor IX Complex J7194 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Prolastin Alpha1-Proteinase Inhibitor (Human) J0256 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Radicava Edaravone J1301 Radicava (edaravone) MP-RX-FP-75-23
Rebinyn Coagulation Factor IX (Recombinant) Glycopegylated J7203 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Reblozyl Luspatercept-aamt J0896 Luspatercept (Reblozyl) MP-RX-FP-76-23
Recombinate Antihemophilic Factor (Recombinant) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Remicade Infliximab J1745 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Renflexis Infliximab-abda Q5104 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Retacrit Inj retacrit esrd on dialysi Q5105 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions NCD: 110.21 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
Retisert Fluocinolone acetonide intravitreal implant J7311 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
Riabni Rituximab Q5123 Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23
RiaSTAP Fibrinogen Concentrate (Human) J7178 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Rituxan Rituximab J9312 Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23
Rituxan Hycela Rituximab J9311 Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23
Rixubis Coagulation Factor IX (Recombinant) J7200 Agents for Hemophilia B: Factor IX Human, Purified [Alphanine], Factor IX Complex Human [Profilnine], Coagulation Factor IX Recombinant [Benefix, Ixinity, Rixubis], Factor IX Fc Fusion Protein Recombinant [Alprolix], Factor IX Albumin Fusion Protein Recombinant [Idelvion], Coagulation Factor IX Recombinant, GlycoPEGylated [Rebinyn] MP-RX-FP-03-23
Ruconest C1 Esterase Inhibitor (Recombinant) J0596 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Ruxience Rituximab Q5119 Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23
Sajazir Icatibant Acetate J1744 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
SandoSTATIN Octreotide injection, non-depot J2354 Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) MP-RX-FP-65-23
SandoSTATIN LAR Depot Octreotide injection, depot J2353 Octeotride Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR) MP-RX-FP-65-23
Saphnelo Anifrolumab-fnia J0491 Saphnelo (anifrolumab-fnia) MP-RX-FP-80-23
SevenFact Coagulation Factor VIIa (Recombinant)-jncw J7212 Select Clotting Agents for Bleeding Disorders: Anti-Inhibitor Coagulant Complex [Feiba NF], Coagulation Factor X, Human plasma-derived [Coagadex], Factor IIa Recombinant [Novoseven RT, SevenFact], Factor XIII [Corifact, Tretten], Fibrinogen Concentrate [RiaSTAP, Fibryga] MP-RX-FP-82-23
Simponi Aria Golimumab J1602 Tumor Necrosis Factor Antagonists [Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis)] MP-RX-FP-96-23
Skyrizi IV Risankizumab-rzaa J2327 Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] MP-RX-FP-61-23
Soliris Eculizumab J1300 Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) MP-RX-FP-19-23
Epysqli eculizumab-aagh J3590 Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) MP-RX-FP-19-23
Somatuline Depot Lanreotide Acetate J1930 Lanreotide (Somatuline Depot) MP-RX-FP-83-23
Spinraza Nusinersen J2326 Spinraza (nusinersen) MP-RX-FP-84-23
Stelara IV Ustekinumab, iv inject, 1 mg J3358 Ustekinumab agents (Stelara, Selarsdi, Wezlana, Pyzchiva, Imuldosa) MP-RX-FP-85-23
Wezlana Ustekinumab, iv inject, 1 mg J3358, Q5137, Q5138 Ustekinumab agents (Stelara, Selarsdi, Wezlana, Pyzchiva, Imuldosa) MP-RX-FP-85-23
Selarsdi Ustekinumab, iv inject, 1 mg J3358 Ustekinumab agents (Stelara, Selarsdi, Wezlana, Pyzchiva, Imuldosa) MP-RX-FP-85-23
Pyzchiva Ustekinumab, iv inject, 1 mg J3358 Ustekinumab agents (Stelara, Selarsdi, Wezlana, Pyzchiva, Imuldosa) MP-RX-FP-85-23
Imuldosa Ustekinumab, iv inject, 1 mg J3358 Ustekinumab agents (Stelara, Selarsdi, Wezlana, Pyzchiva, Imuldosa) MP-RX-FP-85-23
Syfovre Pegcetacoplan J2781 Syfovre (pegcetacoplan) MP-RX-FP-86-23
Sylvant Siltuximab J2860 Sylvant (siltuximab) MP-RX-FP-87-23
Synojoynt Sodium Hyaluronate (Viscosupplement) J7331 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Synvisc Hylan J7325 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Synvisc-One Hylan J7325 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
TACROLIMUS IMME REL ORAL 1MG Tacrolimus immediate release J7507 Immunosuppressive Drugs LCD - Immunosuppressive Drugs (L33824) (cms.gov)
Takhzyro Lanadelumab-flyo J0593 Hereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, Orladeyo MP-RX-FP-36-23
Tepezza Teprotumumab-trbw J3241 Teprotumumab-trbw (Tepezza) MP-RX-FP-89-23
Tezspire Tezepelumab-ekko J2356 Tezepelumab-ekko (Tezspire) MP-RX-FP-90-23
Tevimbra tislelizumab-jsgr J3590, J9999 Tevimbra_PartB_MedPol_2024 MP-RX-FP-155-24
Tremfya Guselkumab J1628 Monoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)] MP-RX-FP-61-23
Triesence Triamcinolone acetonide preservative-free J3300 Triamcinolone acetonide injectable suspension [Xipere, Triesence] MP-RX-FP-93-23
Triferic Ferric pyrophosphate citrate J1443 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Triferic AVNU Ferric pyrophosphate citrate J1445 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Triluron Sodium Hyaluronate (Viscosupplement) J7332 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Trivisc Sodium Hyaluronate (Viscosupplement) J7329 Hyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3] MP-RX-FP-38-23
Trogarzo Ibalizumab-uiyk J1746 Ibalizumab-uiyk (Trogarzo) MP-RX-FP-95-23
Truxima Rituximab Q5115 Rituximab Agents (Including Rituxan Hycela®) for Non-Oncology and Oncology-Related Indications MP-RX-FP-78-23
Tymlos Abaloparatide C9399; J3490; J3590 Human Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity) MP-RX-FP-37-23
Tyruko Natalizumab-sztn Q5134 Natalizumab Agents (Tysabri, Tyruko) MP-RX-FP-97-23
Tysabri Natalizumab J2323 Natalizumab Agents (Tysabri, Tyruko) MP-RX-FP-97-23
Udenyca Pegfilgrastim-cbqv Q5111 Colony Stimulating Factors MP-RX-FP-18-23
Ultomiris Ravulizumab-cwvz J1303 Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) MP-RX-FP-19-23
Uplizna Inebilizumab-cdon J1823 Uplizna (inebilizumab-cdon) MP-RX-FP-98-23
Venofer Iron sucrose J1756 Iron Agents: Ferumoxytol (Feraheme) Ferric carboxymaltose (Injectafer), Sodium ferric gluconate/sucrose complex (Ferrlecit), Iron dextran (Infed), Ferric derisomaltose (Monoferric), Ferric pyrophosphate citrate (Triferric, Triferic AVNU), Iron sucrose (Venofer) MP-RX-FP-44-23
Vimizim Elosulfase Alfa J1322 Vimizim (elosulfase alfa) MP-RX-FP-102-23
Visudyne Verteporfin J3396 Verteporfin [Visudyne] MP-RX-FP-101-23
Vonvendi  Von Willebrand Factor (Recombinant) J7179 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Vpriv Velaglucerase Alfa J3385 Enzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv) MP-RX-FP-29-23
Vyepti Eptinezumab-jjmr J3032 Eptinezumab-jjmr (Vyepti) MP-RX-FP-103-23
Wilate Antihemophilic Factor/von Willebrand Factor Complex (Human) J7183 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Xeomin IncobotulinumtoxinA J0588 Botulinum Toxins LCD: L33274 - Botulinum Toxins
Xiaflex Collagenase Clostridium Histolyticum J0775 Xiaflex (collagenase clostridium histolyticum) injection MP-RX-FP-104-23
Xipere Triamcinolone acetonide J3299 Triamcinolone acetonide injectable suspension [Xipere, Triesence] MP-RX-FP-93-23
Xolair Omalizumab J2357 Omalizumab [Xolair] MP-RX-FP-105-23
Xyntha Solofuse Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) J7192 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Xyntha  Antihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor) J7185 Agents for Hemophilia A and Von Willebrand Disease: Antihemophilic Factor VIII Human [Koate, Hemofil-M], Antihemophilic Factor (Recombinant) Plasma/Albumin-Free [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse], Antihemophilic Factor (factor VIII) – Long acting [– Adynovate, Jivi, Eloctate, Esperoct, Altuviiio], Anti-hemophilic bispecific factor (Factor IXa- and Factor X-)[ Hemlibra (emicizumab-kxwh)], Anti-hemophilic Factor VIII (Recombinant), Porcine Sequence [Obizur], Anti-hemophilic Factor VIII/von Willebrand Factor Complex [Alphanate, Humate-P, Wilate], von Willebrand factor, Recombinant [Vonvendi] MP-RX-FP-02-23
Yutiq Fluocinolone acetonide intravitreal implant J7314 Intravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)] MP-RX-FP-43-23
Zaltrap Aflibercept J9400 Ziv-aflibercept (Zaltrap®) MP-RX-FP-107-23
Zarxio Filgrastim-sndz Q5101 Colony Stimulating Factors MP-RX-FP-18-23
Zemaira Alpha1-Proteinase Inhibitor (Human) J0256 Alpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira] MP-RX-FP-06-23
Fylnetra pegfilgrastim-pbbk Q5130 Colony Stimulating Factors MP-RX-FP-18-23
Nypozi filgrastim-txid C9399, J3590 Colony Stimulating Factors MP-RX-FP-18-23
Releuko filgrastim-ayow Q5125 Colony Stimulating Factors MP-RX-FP-18-23
Stimufend pegfilgrastim-fpgk Q5127 Colony Stimulating Factors MP-RX-FP-18-23
Ziextenzo Pegfilgrastim-bmez Q5120 Colony Stimulating Factors MP-RX-FP-18-23
Zinplava  Bezlotoxumab J0565 Bezlotoxumab (Zinplava) MP-RX-FP-109-23
Zirabev Bevacizumab Q5118 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, and Zirabev) MP-RX-FP-13-23
Breyanzi Lisocabtagene maraleucel Q2054 Lisocabtagene maraleucel (Breyanzi®) NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Carvykti Ciltacabtagene autoleucel Q2056 Ciltacabtagene autoleucel (Carvykti®) NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Kymriah Tisagenlecleucel Q2042 Tisagenlecleucel (Kymriah®) NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Alymsys bevacizumab-maly Q5126 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) MP-RX-FP-13-23
Avzivi bevacizumab-tnjn J3490, J3590 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) MP-RX-FP-13-23
Vegzelma bevacizumab-adcd Q5129 Bevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi) MP-RX-FP-13-23
Ahzantive aflibercept-mrbb J3590 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Alymsys intravitreal bevacizumab-maly Q5126 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Avastin intravitreal bevacizumab J9035 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Beovu Brolucizumab-dbll J0179 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Byooviz ranibizumab-nuna Q5128 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Cimerli ranibizumab-eqrn Q5124 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Enzeevu aflibercept-abzv J3590 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Eylea Aflibercept J0178 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Lucentis Ranibizumab J2778 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Mvasi intravitreal bevacizumab-awwb Q5107 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Susvimo Ranibizumab J2779 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Vabysmo Faricimab-svoa J2777 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Vegzelma intravitreal bevacizumab-adcd Q5129 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Zirabev intravitreal bevacizumab-bvzr Q5118 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Izervay Avacincaptad Pegol C9160 Avacincaptad pegol intravitreal solution (Izervay®) MP-RX-FP-117-24
Adakveo Crizanlizumab-tmca J0791 Crizanlizumab-tmca (Adakveo®) MP-RX-FP-118-24
Jemperli Dostarlimab-gxly J9272 Dostarlimab-gxly (Jemperli®) MP-RX-FP-119-24
Elrexfio Elranatamab-bcmm J3490, J3590, J9999, C9165 Elranatamab-bcmm (Elrexfio®) MP-RX-FP-120-24
Epkinly Epcoritamab-bysp J9321 Epcoritamab-bysp (Epkinly®) MP-RX-FP-121-24
Columvi Glofitamab-gxbm J9286 Glofitamab-gxbm (Columvi®) MP-RX-FP-122-24
Boniva Ibandronate sodium injection J1740 IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®, Jubbonti®, Wyost®, Xgeva®), Ibandronate IV (Boniva®) MP-RX-FP-123-24
Prolia Denosumab J0897 IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®, Jubbonti®, Wyost®, Xgeva®), Ibandronate IV (Boniva®) MP-RX-FP-123-24
Jubbonti denosumab-bbdz Q5136, J3590 IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®, Jubbonti®, Wyost®, Xgeva®), Ibandronate IV (Boniva®) MP-RX-FP-123-24
Wyost denosumab-bbdz Q5136, J3590 IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®, Jubbonti®, Wyost®, Xgeva®), Ibandronate IV (Boniva®) MP-RX-FP-123-24
Xgeva Denosumab J0897 IV Biphosphonate and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia®, Jubbonti®, Wyost®, Xgeva®), Ibandronate IV (Boniva®) MP-RX-FP-123-24
Lumizyme alglucosidase alfa J0221 Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®) MP-RX-FP-124-24
Nexviazyme avalglucosidase alfa-ngpt J0219 Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®) MP-RX-FP-124-24
Pombiliti cipaglucosidase alfa-atga J3490, J3590, S9357 Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®) MP-RX-FP-124-24
Omvoh Mirikizumab-mrkz J3590 Mirikizumab-mrkz (Omvoh®) MP-RX-FP-125-24
Elahere Mirvetuximab Soravtansine-gynx J9063 Mirvetuximab soravtansine-gynx (Elahere®) MP-RX-FP-126-24
Poteligeo mogamulizumab-kpkc, 1 mg J9204 Mogamulizumab-kpkc (Poteligeo®) MP-RX-FP-127-24
Mozobil plerixafor J2562 Plerixafor (Mozobil®) MP-RX-FP-128-24
Danyelza Naxitamab-gqgk J9348 Naxitamab-gqgk (Danyelza®) MP-RX-FP-129-24
Zometa Zoledronic J3489 Zoledronic acid (Zometa®) MP-RX-FP-130-24
Portrazza necitumumab, 1 mg J9295 Necitumumab (Portrazza®) MP-RX-FP-131-24
Arzerra Ofatumumab J9302 Ofatumumab (Arzerra®) MP-RX-FP-132-24
kimyrsa oritavancin, 10mg J2406 Oritavancin (Orbactiv®, Kimyrsa®) MP-RX-FP-133-24
orbactiv oritavancin, 10mg J2407 Oritavancin (Orbactiv®, Kimyrsa®) MP-RX-FP-133-24
Signifor Pasireotide Diaspartate C9399, J3490, J3590 Pasireotide (Signifor®, Singnifor LAR®) MP-RX-FP-134-24
Signifor LAR Pasireotide Pamoate J2502 Pasireotide (Signifor®, Singnifor LAR®) MP-RX-FP-134-24
Empaveli Pegcetacoplan J3490, C9399 Pegcetacoplan (Empaveli®) MP-RX-FP-135-24
Veopoz Pozelimab-bbfg J3590, C9399 Pozelimab-bbfg (Veopoz®) MP-RX-FP-136-24
Azedra iobenguane I 131 A9590 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) MP-RX-FP-137-24
Lutathera lutetium Lu 177 dotatate A9513 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) MP-RX-FP-137-24
Pluvicto Lutetium lu 177 vipivotide tetraxetan A9607 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) MP-RX-FP-137-24
Zevalin Y-90 Ibritumomab Tiuxetan A9543 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®) MP-RX-FP-137-24
Zynyz Retifanlimab-dlwr J9345 Retifanlimab-dlwr (Zynyz®) MP-RX-FP-138-24
Ryzneuta efbemalenograstim alfa-vuxw J3490, J3590 Colony Stimulating Factors MP-RX-FP-18-23
Spevigo Spesolimab-sbzo J1747 Spesolimab-sbzo (Spevigo®) MP-RX-FP-140-24
Enjaymo Sutimlimab-jome J1302 Sutimlimab-jome (Enjaymo®) MP-RX-FP-141-24
Talvey Talquetamab-tgvs J3490, J3590, J9999, C9163 Talquetamab-tgvs (Talvey®) MP-RX-FP-142-24
Kimmtrak Tebentafusp-tebn J9274 Tebentafusp-tebn (Kimmtrak®) MP-RX-FP-143-24
Tecvayli Teclistamab-cqyv J9380 Teclistamab-cqyv (Tecvayli®) MP-RX-FP-144-24
Tivdak Tisotumab Vedotin-tftv J9273 Tisotumab vedotin-tftv (Tivdak®) MP-RX-FP-145-24
Qalsody Tofersen J1304 Tofersen (Qalsody®) MP-RX-FP-146-24
Loqtorzi Toripalimab-tpzi J3490, J3590, C9399 Toripalimab-tpzi (Loqtorzi®) MP-RX-FP-147-24
Yondelis Trabectedin J9352 Trabectedin (Yondelis®) MP-RX-FP-148-24
Adbry Tralokinumab-ldrm J3490, J3590, C9399 Tralokinumab-ldrm (Adbry®) MP-RX-FP-149-24
Imjudo Tremelimumab-actl J9347 Tremelimumab-actl (Imjudo®) MP-RX-FP-150-24
Briumvi ublituximab-xiiy J2329 Ublituximab-xiiy (Briumvi®) MP-RX-FP-151-24
Reclast Zoledronic J3489 Zoledronic acid (Reclast®) MP-RX-FP-152-24
Yervoy Ipilimumab J9228 Ipilimumab (Yervoy®) MP-RX-FP-106-23
Zepzelca Lurbinectedin J9223 Lurbinectedin (Zepzelca®) MP-RX-FP-108-23
Zynlonta loncastuximab tesirine-lpyl J9359 Loncastuximab tesirine-lpyl (Zynlonta®) MP-RX-FP-110-23
Camcevi Leuprolide mesylate J1952 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Eligard Leuprolide J9217 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Fensolvi Leuprolide J1951 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Firmagon Firmagon J9155 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Firmagon (240 MG Dose) Degarelix J9155 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Lupaneta Leuprolide J1950 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Lupron Depot (1-Month) Leuprolide J1950 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Lupron Depot (3-Month) Leuprolide J9217 (Non-Oncology), J1950 (Oncology) GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Lupron Depot (6-Month) Leuprolide J9217 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Supprelin Leuprolide J9217 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
TRELSTAR Triptorelin J3315 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Triptodur Triptorelin pamoate extended-release J3316 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Zoladex Goserelin J9202 GnRH analogs for non-oncology and oncology-related indications MP-RX-FP-34-23
Asceniv J3590 Immunoglobulins MP-RX-FP-40-23
Octagam Immune Globulin (Human) IV Immunoglobulins MP-RX-FP-40-23
Gammaplex Immune Globulin (Human) IV J3590 Immunoglobulins MP-RX-FP-40-23
Gammaked Immune Globulin (Human) IV J3590 Immunoglobulins MP-RX-FP-40-23
Flebogamma DIF Immune Globulin (Human) IV J3590 Immunoglobulins MP-RX-FP-40-23
Cuvitru Immune Globulin (Human) Subcutaneous J3590 Immunoglobulins MP-RX-FP-40-23
Bivigam Immune Globulin (Human) IV J3590 Immunoglobulins MP-RX-FP-40-23
Cutaquig Immune Globulin (Human) IV J1551 Immunoglobulins MP-RX-FP-40-23
Hizentra Immune Globulin (Human) IV J1559 Immunoglobulins MP-RX-FP-40-23
Xembify Immune Globulin (Human) IV J1558 Immunoglobulins MP-RX-FP-40-23
Hercessi trastuzumab-strf J3590 Trastuzumab – Trastuzumab Biologics MP-RX-FP-161-24
IXEMPRA Ixabepilone J9207 Ixabepilone (Ixempra®) MP-RX-FP-46-23
Margenza Margetuximab J9353 Margetuximab-cmkb (Margenza®) MP-RX-FP-56-23
Monjuvi Tafasitamab J9349 Tafasitamab-cxix (Monjuvi®) MP-RX-FP-57-23
Mylotarg gemtuzumab ozogamicin J9203 Gemtuzumab ozogamicin (Mylotarg®) MP-RX-FP-62-23
Sarclisa Isatuximab J9227 isatuximab (Sarclisa®) MP-RX-FP-81-23
Torisel Temsirolimus J9330 Temsirolimus (Torisel®) MP-RX-FP-91-23
Vectibix Panitumumab J9303 Panitumumab (Vectibix®) MP-RX-FP-99-23
Adcetris Brentuximab J9042 Brentuximab vedotin (Adcetris®) MP-RX-FP-01-23
Alimta Pemetrexed J9305 Pemetrexed (Alimta®, Pemfexy®, Pemrydi®) MP-RX-FP-05-23
Pemetrexed Pemetrexed J9314, J9322, J9323, J9294, J9296, J9297 Pemetrexed (Alimta®, Pemfexy®, Pemrydi®) MP-RX-FP-05-23
Pemfexy Pemetrexed J9304 Pemetrexed (Alimta®, Pemfexy®, Pemrydi®) MP-RX-FP-05-23
Pemrydi Pemetrexed J9324 Pemetrexed (Alimta®, Pemfexy®, Pemrydi®) MP-RX-FP-05-23
Bavencio Avelumab J9023 Avelumab (Bavencio®) MP-RX-FP-09-23
Belrapzo Bendamustine J9036 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
Bendeka Bendamustine J9034, J9058, J9059 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
Treanda Bendamustine J9033 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
Vivimusta Bendamustine J9056 Bendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®) MP-RX-FP-10-23
Abecma Idecabtagene vicleucel Q2055 Idecabtagene vicleucel (Abecma®) NCD - Chimeric Antigen Receptor (CAR) T-cell Therapy (110.24) (cms.gov)
Tecartus Brexucabtagene autoleucel Q2053 Brexucabtagene autoleucel (Tecartus®) NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Yescarta axicabtagene ciloleucel Q2041 Axicabtagene ciloleucel (Yescarta®) NCD 110.24: Chimeric Antigen Receptor (CAR) T-cell Therapy
Besponsa Inotuzumab J9229 Inotuzumab ozogamicin (Besponsa®) MP-RX-FP-12-23
Blincyto Blinatumomab J9039 Blinatumomab (Blyncito®) MP-RX-FP-14-23
Cyramza Ramucirumab J9308 Ramucirumab (Cyramza®) MP-RX-FP-20-23
Empliciti Elotuzumab J9176 Elotuzumab (Empliciti®) MP-RX-FP-26-23
Erbitux Cetuximab J9055 Cetuximab (Erbitux®) MP-RX-FP-30-23
Halaven Eribulin J9179 Eribulin mesylate (Halaven®) MP-RX-FP-35-23
Imfinzi Durvalumab J9173 Durvalumab (Imfinzi®) MP-RX-FP-39-23
Jevtana Cabazitaxel J9043, J9064 Cabazitaxel (Jevtana®) MP-RX-FP-47-23
Kadcyla ado-trastuzumab emtansine J9354 Ado-trastuzumab (Kadcyla®) MP-RX-FP-48-23
Kyprolis Carfilzomib J9047 Carfilzomib (Kyprolis®) MP-RX-FP-51-23
Lunsumio mosunetuzumab-axgb J9350 Mosunetuzumab-axgb (Lunsumio®) MP-RX-FP-55-23
Opdivo Nivolumab J9299 Nivolumab (Opdivo®) and Nivolumab and hyaluronidase-nvhy (Opdivo Qvantig®) MP-RX-FP-66-23
Opdivo Qvantig Nivolumab and hyaluronidase-nvhy J9999  Nivolumab (Opdivo®) and Nivolumab and hyaluronidase-nvhy (Opdivo Qvantig®) MP-RX-FP-66-23
Polivy Polatuzumab J9309 Polatuzumab vedotin-piiq (Polivy®) MP-RX-FP-73-23
Opdualag nivolumab and relatlimab-rmbw J9298 Nivolumab and relatlimab-rmbw (Opdualag®) MP-RX-FP-67-23
Abraxane Paclitaxel J9264 Paclitaxel, Protein Bound (Abraxane®) MP-RX-FP-69-23
PACLitaxel Protein-Bound Part Paclitaxel J9264 Paclitaxel, Protein Bound (Abraxane®) MP-RX-FP-69-23
Padcev Enfortumab J9177 Enfortumab vedotin-ejfv (Padcev®) MP-RX-FP-70-23
Perjeta Pertuzumab J9306 Pertuzumab (Perjeta®) MP-RX-FP-71-23
Polivy Polatuzumab J9309 Polatuzumab vedotin-piiq (Polivy®) MP-RX-FP-73-23
Rybrevant amivantamab-vmjw J9061 Amivantamab-vmjw (Rybrevant®) MP-RX-FP-79-23
Tecentriq Atezolizumab J9022 Atezolizumab (Tecentriq), Atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) MP-RX-FP-88-23
Tecentriq Hybreza Atezolizumab and hyaluronidase-tqjs J9024 Atezolizumab (Tecentriq), Atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) MP-RX-FP-88-23
Trodelvy Sacituzumab J9317 Sacituzumab govitecan (Trodelvy®) MP-RX-FP-94-23
Niktimvo Axatilmab-csfr J3590, C9399 Axatilmab-csfr (Niktimvo) MP-RX-FP-159-24
Pedmark Sodium Thiosulfate (Otoprotective) J0208  Sodium thiosulfate injection (Pedmark) MP-RX-FP-160-24
Herzuma Trastuzumab-pkrb Q5113 Trastuzumab Agents MP-RX-FP-161-24
Kanjinti Trastuzumab Q5117 Trastuzumab Agents MP-RX-FP-161-24
Ogivri Trastuzumab-dkst Q5114 Trastuzumab Agents MP-RX-FP-161-24
Ontruzant trastuzumab-dttb Q5112 Trastuzumab Agents MP-RX-FP-161-24
Phesgo pertuzumab, trastuzumab, and hyaluronidase-zzxf J9316 Trastuzumab Agents MP-RX-FP-161-24
Trazimera Trastuzumab-qyyp Q5116 Trastuzumab Agents MP-RX-FP-161-24
Vyloy Zolbetuximab-clzb J3590, C9399, J9999 Zolbetuximab-clzb (Vyloy) MP-RX-FP-162-24
Elevidys Delandistrogene moxeparvovec-rokl J1413 Delandistrogene moxeparvovec-rokl (Elevidys) MP-RX-FP-163-24
Vyalev Levodopa Combinations J7799 Foscarbidopa and Foslevodopa (Vyalev) MP-RX-FP-164-24
Vyafuser Subcutaneous Infusion Pump E0781, E1399 Foscarbidopa and Foslevodopa (Vyalev) MP-RX-FP-164-24
Cosentyx Secukinumab C9399; J3490; J3590 Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] MP-RX-FP-60-23
Siliq brodalumab C9399; J3490; J3590 Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] MP-RX-FP-60-23
Taltz Ixekizumab C9399; J3490; J3590 Monoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)] MP-RX-FP-60-23
Adacel Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap) 90715 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
Boostrix Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap) 90715 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
Tetanus-Diphtheria Toxoids Td Tetanus-Diphtheria Toxoids (Td) 90714 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
Engerix-B Hepatitis B Vaccine (Recomb) 90756 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
Heplisav-B Hepatitis B Vaccine Recombinant Adjuvanted 90739 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
PreHevbrio Hepatitis B Vaccine 3-Antigen Recombinant 90759 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
Recombivax HB Hepatitis B Vaccine (Recomb) 90746 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
Twinrix Hepatitis A (Inactivated)-Hepatitis B (Recombinant) Vaccines 90636 Hepatitis B and Tetanus-Containing Vaccines MP-RX-FP-156-24
Yesafili aflibercept J3590 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Opuviz aflibercept J3590 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Pavblu aflibercept-ayyh J3590 Vascular Endothelial Growth Factor (VEGF) Inhibitors MP-RX-FP-100-23
Piasky crovalimab-akkz J3590 Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) MP-RX-FP-19-23
Bkemv eculizumab J3590 Complement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb) MP-RX-FP-19-23
Tyenne tocilizumab-aazg C9399 Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara), Tofidence (Tocilizumab-bavi) MP-RX-FP-59-23
Tofidence Tocilizumab-bavi J5133 Monoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara), Tofidence (Tocilizumab-bavi) MP-RX-FP-59-23
Rytelo Imetelstat C9399; J3490; J9999 Imetelstat (Rytelo) MP-RX-FP-157-24
Lymphir Denileukin diftitox-cxdl C9399; J3490; J9999 Denileukin diftitox-cxdl (Lymphir) MP-RX-FP-158-24
Leqembi Lecanemab-irmb J0174 Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) NCD - Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) (200.3) (cms.gov)
Kisunla Donanemab-azbt J0175 Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) NCD - Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) (200.3) (cms.gov)
Truvada Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg, oral J0750 Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Tracking Sheet (cms.gov)
Descovy Emtricitabine 200 mg and tenofovir alafenamide 25 mg, oral J0751 Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Tracking Sheet (cms.gov)
Apretude Injection, cabotegravir, 1 mg J0739 Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Tracking Sheet (cms.gov)
Bizengri zenocutuzumab-zbco C9399, J9999 Bizengri (zenocutuzumab-zbco) MP-RX-FP-165-25
Kinsula Donanemab-azbt J0175 Donanemab-azbt (Kisunla) MP-RX-FP-166-25
Ziihera Zanidatamab-hrii C9399, J9999 Ziihera (Zanidatamab-hrii) MP-RX-FP-167-25

Políticas de Manejo de Utilización Clínica

Las Políticas de Utilización Médica definen la manera en que MMM Holdings LLC y sus subsidiarias identifican y evalúan solicitudes de servicios específicos y facilitan un proceso de determinación consistente de acuerdo con las regulaciones de los Centros de Medicare y Medicaid (CMS).

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Medical Policy Title Medical Policy Number
Solumedrol IV MP-ME-FP-01-24
H2 blockers IV MP-ME-FP-02-24
Proton Pump Inhibitors (PPIs) MP-ME-FP-03-24
5-HT3 receptor antagonists IV MP-ME-FP-04-24
Metoclopramide IV MP-ME-FP-05-24
IV Antibiotics MP-IV-FP-01-23
Sub-Acute Levels of Care (Skill Nursing and Rehab) MP-HSIP-005-FP-01-23
Occupational, Speech and Physical Therapy Guidelines Occupational, Speech and Physical Therapy Guidelines
Psychiatric Diagnostic Evaluation and Psychotherapy Services MP-EM-FP-02-23
Neuropsychological Tests MP-EM-FP-03-23
GMT Medicare Crosswalk 2025 GMT Medicare Crosswalk 2025
Molecular Testing Review Criteria Molecular Testing Review Criteria
Home Visits - Mental Health MP-EM-FP-01-23
Authorization of Services Unit - Clinical Criteria Authorization of Services Unit - Clinical Criteria
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