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.

Effective July 1, 2011
For the following medications, please contact HIRSP Prior Authorization Services at:
1-(866)-841-6572.
Code Generic Name Brand Name
J9264 Paclitaxel Abraxane
J9001 Doxorubicin Adriamycin
J9305 Pemetrexed Alimta
J0256 Alpha 1 Proteinase Inhibitor Aralast
J0881 Darbopoetin Aranesp
J0882 Darbopoetin Aranesp
J9035 Bevacizumab Avastin
J0585 Onabotulisum toxin A Botox Injections
J9010 Alemtuzumab Campath
J9206 Irinotecan Camptosar
J0718 Certilizumab Cimzia
J0886 Epoetin Epogen
J9055 Cetuximab Erbitux
J0180 Agalsidase Famraszyme
J9201 Gemcitibine Gemzar
J9350 Topotecan Hycamtin
J1559 Hizentra Immune Globulin
J1561 Gamunex Immune Globulin
J1562 Vivaglobin Immune Globulin
J1568 Octagam Immune Globulin
J1569 Privigen Immune Globulin
J1572 Flebogamma Immune Globulin
J1745 Infliximab Remicade
Q3025  Interferon Beta 1A Interferon
J2820 Sargramostim Leukine
J9217 Leuoprolide Lupron
J2562 Plerixator Mozobil
J1440 Filgrastim Neupogen
J1441 Filgrastim Neupogen
J2796 Romiplostim Nplate
J0129 Abatacept Orencia
J2505 Pegfilgrastim Neulasta
J0885 Epoetin Procrit
J9310 Rituximab Rituxan
J9265 Paclitaxel Taxol
J9171 Doxetaxel Taxotere
J2323 Natalizumab Tysarbri
J9303 Panitumumab Vectibix
J9041 Bortezomib Velcade
J9025 Azacitidine Vidaza