Specialty Medications Requiring Prior Authorization

Most specialty medications as defined in your HIRSP policy require Prior Authorization.

Specialty drugs are prescription drugs that have one or more of the following characteristics as determined by HIRSP:

  1. expensive with high medical cost potential;
  2. produced through a biotechnology mechanism/process;
  3. administered by injection;
  4. association with complex clinical management;
  5. requires close patient monitoring; and
  6. distributed exclusively through a designated specialty pharmacy.

For most specialty medications please contact the MedTrak Dedicated Pharmacy Unit at 1-(800)-757-5576, or visit MedTrak Pharmacy Services. In addition, the following list of specialty drugs also requires prior authorization. Please be sure to review this list AND the list provided by the MedTrak Pharmacy Services to determine if your specialty medications require prior authorization.

For the following medications, please contact HIRSP Prior Authorization Services at:
1-(866)-841-6572.
Code Brand Name Generic Name
J9264 / J9265 Abraxane Paclitaxel
J3262
Effective 3/1/2013		 Actemra Tocilizumab
J9000 / J9001 Adriamycin Doxorubicin
J9305 Alimta Pemetrexed
J0256 / J2057 Aralast Alpha1 Proteinase inhibitor
J0881 / J0882 Aranesp Darbepoetin
J9302
Effective 3/1/2013		 Arzerra Ofatumumab
J9035
Chemo only		 Avastin Bevacizumab
J7195
Effective 3/1/2013		 Bebulin / Profilnine Factor IX
J0585 Botox Onabotulinum toxin
J0585 Botox Onabotulinum toxin
J9010 Campath Alemtuzumab
J9206 Camptosar Irinotecan
J9263 Eloxatin Oxaliplatin
J0885 / J0886 / Q4081 Epogen Epoetin alfa
J9055 Erbitux Cetuximab
J0180 Fabrazyme Agalsidase beta
J7185 / J7192 Factor VIII Anti-hemophil Factor
J1572 Flebogamma Immune Globulin
J1569 Gammagard Immune Globulin
J1561 Gamunex Immune Globulin
J9201 Gemzar Gemcitabine hydrochloride
J9179
Effective 3/1/2013		 Halaven Eribulin
J9355 Herceptin Trastuzumab
J1559 Hizentra Immune Globulin
J7186 / J7187 Humate P Factor VIII / Von Willebrand Factor
J9351 Hycamtin Topotecan
J1826 / Q3025 / Q3026 Interferon Interferon Beta 1A
J2820 Leukine Sargramostim
J2778
Effective 3/1/2013		 Lucentis Ranibizumab
J9217 / J9218 / J9219 / J1950 Lupron Depot Leuprolide
J2562 Mozobil Plerixafor
J2796 Nplate Romiplostim
J2505 Neulasta Pegfilgrastim
J1440 / J1441 Neupogen Filgrastim
J1568 Octagam Immune Glogulin
J0129 Orencia Abatacept
J1459 Privigen Immune Globulin
J0885 / J0886 Procrit Epoetin
J0897
Effective 3/1/2013		 Prolia / Xgeva Denosumab
J1745 Remicade Infliximab
J3285 / J7686
J7686 Eff. 3/1/13		 Remodulin Treprostinil
J9310 Rituxan Rituximab
J9265 Taxol Paclitaxel
J9171 Taxotere Docetaxel
J9033 Treanda Bendamustine
J2323 Tysabri Natalizumab
J9303 Vectibix Panitumumab
J9041 Velcade Bortezomib
J9228 Yervoy Ipilimumab
J9025 Vidaza Azacitidine
J1562 Vivaglobin Immune Globulin
J7187 Von Willebrand Factor Factor VIII
J2357 Xolair Omalizumab
J7185 Xyntha Factor VIII