As a reminder, Outpatient Physician/Facility Administered Drugs are subject to authorization criteria consistent with Alliance pharmacy benefits, which are based on the decision of the Alliance’s Pharmacy and Therapeutics Committee. Prior authorization is required for Outpatient Physician Administered Drugs.
If an Outpatient Physician/Facility Administered Drug requiring prior authorization has no prior authorization criteria, it will be reviewed by Alliance staff for medical necessity. For details on the authorization review process for Outpatient Physician/Facility Administered Drugs, please refer to Section 16 of the Alliance Provider Manual at http://www.ccah-alliance.org/provider-manual-toc.html. Providers can also reference the Prior Authorization Criteria link on the Pharmacy page of the Alliance provider website at www.ccah-alliance.org/pharmacy.html for more information.
Please note that after June 1, 2019, claims for the following codes will deny if not submitted with an approved Alliance authorization number:
- J2350: INJECTION, OCRELIZUMAB, 1MG
- J1726: INJECTION, HYDROXYPROGESTERONE CAPROATE, (MAKENA), 10MG
- J9035: INJECTION, BEVACIZUMAB, 10MG
- J9306: INJECTION, PERTUZUMAB, 1MG
- J9264: INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1MG
- J9047: INJECTION, CARFILZOMIB, 1MG
- J2353: INJECTION, OCTREOTIDE, DEPOT FORM FOR IM, 1MG
- J9019: INJECTION, ASPARAGINASE (ERWINAZE), 1,000 IU
- J9303: INJECTION, PANITUMUMAB, 10MG
- J3489: INJECTION, ZOLEDRONIC ACID, 1MG
- J1930: INJECTION, LANREOTIDE, 1MG
- J0490: INJECTION, BELIMUMAB, 10MG
- J9070: CYCLOPHOSPHAMIDE, 100MG
- J0289: INJECTION, AMPHOTERICIN B LIPOSOME, 10MG
- J9171: INJECTION, DOCETAXEL, 1MG
- J2182: INJECTION, MEPOLIZUMAB, 1MG
- J2507: INJECTION, PEGLOTICASE, 1MG
- J0775: INJECTION ,COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01MG
- J2562: INJECTION, PLERIXAFOR, 1MG
- J9179: INJECTION, ERIBULIN MESYLATE, 0.1MG
- J9217: LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5MG
- J0485:INJECTION, BELATACEPT, 1MG
- J9202: GOSERELIN ACETATE IMPLANT, PER 3.6MG
- J2796: INJECTION, ROMIPLOSTIM, 10 MCG
- J9033: INJECTION, BENDAMUSTINE HCL (TREANDA), 1MG
- J9266: INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL
- J9050: INJECTION, CARMUSTINE, 100MG
- J9015: INJECTION, ALDESLEUKIN, PER SINGLE DOSE VIAL
- J0630: INJECTION, CALCITONIN SALMON, UP TO 400 UNITS
- J9229: INJECTION, INOTUZUMAB OZOGAMICIN, 0.1MG
- J3316: INJECTION, TRIPTORELIN, EXTENDED-RELEASE, 3.75 MG
- J9340: INJECTION, THIOTEPA, 15MG
- J1826: INJECTION, INTERFERON-BETA-1a, 30MCG
- J7316: INJECTION, OCRIPLASMIN, 0.125 MCG
- J0207: INJECTION, AMIFOSTINE, 500MG
- Q2049: INJECTION, DOXORUBICIN HCL, LIPSOMAL, IMPORTED LIPODEX., 10MG
If you have questions, please contact the Alliance Pharmacy department at (831) 430-5507.
