2020 Medical Drug Policies

The drugs listed below have corresponding medical drug policies that contain coverage criteria for how these drugs are covered by UCare when billed under the member’s medical benefit. Medical drug policies are reviewed and approved by UCare’s Pharmacy and Therapeutics Committee and are subject to change. Authorization requests should be submitted and approved prior to dispensing/administering.

Beginning Jan. 1, 2020, Care Continuum, a subsidiary of Express Scripts, will review Medical Drug Prior Authorization requests for all UCare plans.

Submit an authorization request one of the following ways:

Medicare Policies:

The coverage criteria contained in the policy may not apply to UCare Medicare products if Medicare requires different coverage criteria. If Medicare requires different coverage criteria, the applicable NCD or LCD will apply. Find Medical Injectable Drug Prior Authorization Resources for each UCare health plan and forms to request authorizations on our Pharmacy page.

Drug Name HCPCS Code Therapeutic Class Meta
Herceptin J9355 Oncology trastuzumab, excludes biosimilar, 10 mg, 212
Opdivo - Medicare J9299 Oncology nivolumab, 1 mg, 177B, V2
Asparlas J9118 Oncology calaspargase pegol mknl injection, for intravenous use, 218
Revcovi NOC Enzyme Replacement Not Otherwise Classified, 116, V2
Vyondys 53 J9399 Muscular Dystrophy golodirsen intravenous infusion – Sarepta, 219
Nucala J2182 Immunologicals mepolizumab, 1 mg, 131, V2
Simponi Aria J1602 Inflammatory Conditions golimumab, 1 mg, 137, V2
Lemtrada J0202 Multiple Sclerosis alemtuzumab, 1 mg, 139, V2
Ocrevus J2350 Multiple Sclerosis ocrelizumab, 1 mg, 140, V2
Tysabri J2323 Multiple Sclerosis natalizumab, 1 mg, 141, V2
Exondys 51 J1428 Rare/Misc Conditions eteplirsen, 10 mg, 142, V2
Fasenra J0517 Immunologicals benralizumab, 1 mg, 118
Folotyn J9307 Oncology pralatrexate, 1 mg, 160
Herceptin Hylecta J9356 Oncology trastuzumab, 10 mg and Hyaluronidase-oysk, 163
Imfinzi J9173 Oncology durvalumab, 10 mg, 164
Faslodex J9395 Oncology fulvestrant, 25 mg, 159, V2
Vectibix J9303 Oncology panitumumab, 10 mg, 186
Adcetris J9042 Oncology brentuximab vedotin, 1 mg, 145, V2
Alimta J9305 Oncology pemetrexed, 10 mg, 146, V2
Aliqopa J9057 Oncology copanlisib, 1 mg, 147, V2
Arzerra J9302 Oncology ofatumumab, 10 mg, 148, V2
Beleodaq J9032 Oncology belinostat, 10 mg, 150, V2
Blincyto J9039 Oncology blinatumomab, 1 microgram, 152, V2
Gazyva J9301 Oncology obinutuzumab, 10 mg, 161, V2
Halaven J9179 Oncology eribulin mesylate, 0.1 mg, 162, V2
Poteligeo J9204 Oncology mogamulizumab-kpkc, 1 mg, 181, V2
Synribo J9262 Oncology omacetaxine mepesuccinate, 0.01 mg, 184, V2
Yervoy J9228 Oncology ipilimumab, 1 mg, 188, V2
HP Acthar J0800 Rare/Misc Conditions corticotropin, up to 40 units, 210, V2
Epogen J0885 Hematology epoetin alfa, (for non-esrd use), 1000 units, 211, V2
Neupogen - Medicaid, Exchange J1442 Hematology filgrastim (g-csf), excludes biosimilars, 1 microgram, 214A, V2
Azedra (Diagnostic & Therapeutic) A9590 Oncology Iodine i-131 iobenguane, diagnostic, therapeutic, 1 millicurie, 197, V2
Remicade - Medicaid, Exchange J1745 Inflammatory Conditions infliximab, excludes biosimilar, 10 mg, 215A, V2
Rituxan - Medicaid, Exchange J9312 Oncology rituximab, 100 mg, 216A, V2
Velcade - Medicaid, Exchange J9041 Oncology bortezomib (velcade), 0.1 mg, 187A, V2
Duopa J7340 Rare/Misc Conditions Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml, 204
Cimzia J0717 Inflammatory Conditions certolizumab pegol, 1 mg, 205
Chorionic Gonadotropin J0725 Infertility chorionic gonadotropin, per 1,000 usp units, 206
Novarel J0725 Infertility chorionic gonadotropin, per 1,000 usp units, 206
Ovidrel NOC Infertility choriogonadotropin alfa,humrec, 206
Pregnyl J0725 Infertility chorionic gonadotropin, per 1,000 usp units, 206
Belrapzo J9036 Oncology bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mg, 207
Bendeka J9034 Oncology bendamustine hcl (bendeka), 1 mg, 207
Stelara (Subcutaneous) J3357 Inflammatory Conditions Ustekinumab, for subcutaneous injection, 1 mg, 201
Ultomiris J1303 Rare/Misc Conditions emapalumab-lzsg, 1 mg, 199, V2
Neulasta - Medicaid, Exchange J2505 Hematology pegfilgrastim, 6 mg, 213A, V2
Zolgensma NOC Rare/Misc Conditions Not Otherwise Classified, 198
Xiaflex J0775 Rare/Misc Conditions collagenase, clostridium histolyticum, 0.01 mg, 200
Ilaris J0638 Inflammatory Conditions canakinumab, 1 mg, 202
Ilumya J3245 Inflammatory Conditions tildrakizumab, 1 mg, 203
Xolair - Medicaid, Exchange J2357 Immunologicals omalizumab, 5 mg, 132A
Erbitux - Medicaid, Exchange J9055 Oncology cetuximab, 10 mg, 157A
Treanda J9033 Oncology bendamustine hcl (treanda), 1 mg, 207
Tremfya J1628 Inflammatory Conditions guselkumab, 1 mg, 208
Procrit J0885 Hematology epoetin alfa, (for non-esrd use), 1000 units, 211
Dupixent - SPP and IFP only NOC Immunologicals dupilumab subcutaneous injection, 217
Rituxan Hycela J9311 Oncology rituximab 10 mg and hyaluronidase, 209, V2
Glassia J0257 Rare/Misc Conditions alpha 1 proteinase inhibitor (human), (glassia), 10 mg, 101
Prolastin J0256 Rare/Misc Conditions alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg, 101
Zemaira J0256 Rare/Misc Conditions alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg, 101
Evenity J3111 Osteoporosis romosozumab-aqqg, 1 mg, 104
Trogarzo J1746 Rare/Misc Conditions ibalizumab-uiyk, 10 mg, 105
Crysvita J0584 Rare/Misc Conditions burosumab-twza 1 mg, 107
Adagen J2504 Enzyme Replacement pegademase bovine, 25 iu, 108
Aldurazyme J1931 Enzyme Replacement laronidase, 0.1 mg, 109
Elaprase J1743 Enzyme Replacement idursulfase, 1 mg, 110
Cinqair J2786 Immunologicals reslizumab, 1 mg, 106, V2
Xolair - Medicare J2357 Immunologicals omalizumab, 5 mg, 132B
Erbitux - Medicare J9055 Oncology cetuximab, 10 mg, 137B
Lumizyme J0221 Enzyme Replacement alglucosidase alfa, 10 mg, 113
Mepsevii J3397 Enzyme Replacement vestronidase alfa-vjbk, 1 mg, 114
Naglazyme J1458 Enzyme Replacement galsulfase, 1 mg, 115
Vimizim J1322 Enzyme Replacement elosulfase alfa, 1 mg, 117
Gamifant J9210 Rare/Misc Conditions emapalumab-lzsg, 1 mg, 119
Aralast NP J0256 Rare/Misc Conditions alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg, 101
Cablivi C9047 Hematology caplacizumab-yhdp, 1 mg, 124, V2
Fabrazyme J0180 Enzyme Replacement agalsidase beta, 1 mg, 111
Kanuma J2840 Enzyme Replacement sebelipase alfa, 1 mg, 112
Cerezyme J1786 Enzyme Replacement imiglucerase, 10 units, 120
Elelyso J3060 Enzyme Replacement taliglucerase alfa, 10 units, 121
Vpriv J3385 Enzyme Replacement velaglucerase alfa, 100 units, 122
Krystexxa J2507 Rare/Misc Conditions pegloticase, 1 mg, 123
Hemlibra J7170 Hematology emicizumab-kxwh, 0.5 mg, 125
Berinert J0597 Hereditary Angioedema c-1 esterase inhibitor (human), berinert, 10 units, 126
Cinryze J0598 Hereditary Angioedema c-1 esterase inhibitor (human), cinryze, 10 units, 126
Ruconest J0596 Hereditary Angioedema c1 esterase inhibitor (recombinant), ruconest, 10 units, 126
Firazyr J1744 Hereditary Angioedema icatibant, 1 mg, 128
Kalbitor J1290 Hereditary Angioedema ecallantide, 1 mg, 129
Takhzyro J0593 Hereditary Angioedema lanadelumab-flyo, 1 mg, 130
Actemra J3262 Inflammatory Conditions tocilizumab, 1 mg, 133
Benlysta J0490 Inflammatory Conditions belimumab, 10 mg, 134
Entyvio J3380 Inflammatory Conditions vedolizumab, 1 mg, 135
Orencia J0129 Inflammatory Conditions abatacept, 10 mg, 136
Brineura J0567 Rare/Misc Conditions cerliponase alfa, 1 mg, 143
Radicava J1301 Rare/Misc Conditions edaravone, 1 mg, 144
Bavencio J9023 Oncology avelumab, 10 mg, 149
Besponsa J9229 Oncology inotuzumab ozogamicin, 0.1 mg, 151
Cyramza J9308 Oncology ramucirumab, 5 mg, 153
Darzalex J9145 Oncology daratumumab, 10 mg, 154
Elzonris J9269 Oncology tagraxofusp-erzs, 10 mcg, 155
Empliciti J9176 Oncology elotuzumab, 1 mg, 156
Erwinaze J9019 Oncology asparaginase (erwinaze), 1,000 iu, 158
Imlygic J9325 Oncology talimogene laherparepvec, per 1 million plaque forming units, 165
Provenge Q2043 Oncology Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, 184
Sylvant J2860 Oncology siltuximab, 10 mg, 183
Neulasta - Medicare J2505 Hematology pegfilgrastim, 6 mg, 213B, V2
Neupogen - Medicare J1442 Hematology filgrastim (g-csf), excludes biosimilars, 1 microgram, 214B, V2
Remicade - Medicare J1745 Inflammatory Conditions infliximab, excludes biosimilar, 10 mg, 215B, V2
Rituxan - Medicare J9312 Oncology rituximab, 100 mg, 216B, V2
Velcade - Medicare J9041 Oncology bortezomib (velcade), 0.1 mg, 187B, V2
Soliris - Medicare J1300 Rare/Misc Conditions eculizumab, 10 mg, 194B, V2
Stelara (intravenous) J3358 Inflammatory Conditions Ustekinumab, for intravenous injection, 1 mg, V2
Tecentriq J9022 Oncology atezolizumab, 10 mg, 185, V2
Zulresso C9055 Rare/Misc Conditions 193
Spinraza J2326 Rare/Misc Conditions nusinersen, 0.1 mg, 196, V2
Onpattro J0222 Rare/Misc Conditions patisiran, 0.1 mg, 102, V2
Yescarta Q2041 Oncology Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, 189
Zaltrap J9400 Oncology ziv-aflibercept, 1 mg, 190
Luxturna J3398 Rare/Misc Conditions voretigene neparvovec-rzyl, 1 billion vector genomes, 191
Spravato NOC Rare/Misc Conditions Not Otherwise Classified, 192
Lutathera A9513 Oncology Lutetium lu 177, dotatate, therapeutic, 1 millicurie, 195
Soliris - Medicaid, Exchange J1300 Rare/Misc Conditions eculizumab, 10 mg, 194A
Tegsedi NOC Rare/Misc Conditions Not Otherwise Classified, 103, V2
Haegarda - SPP and IFP only J0599 Hereditary Angioedema c-1 esterase inhibitor (human), (haegarda), 10 units, 127
Jevtana J9043 Oncology cabazitaxel, 1 mg, 166
Kadcyla J9354 Oncology ado-trastuzumab emtansine, 1 mg, 167
Kymriah Q2042 Oncology Tisagenlecleucel, up to 600 million car-positive viable t cells, 169
Kyprolis J9047 Oncology carfilzomib, 1 mg, 170
Lartruvo J9285 Oncology olaratumab, 10 mg, 171
Lumoxiti J9313 Oncology moxetumomab pasudotox-tdfk, 0.01 mg, 173
Mylotarg J9203 Oncology gemtuzumab ozogamicin, 0.1 mg, 174
Oncaspar J9266 Oncology pegaspargase, per single dose vial, 175
Onivyde J9205 Oncology irinotecan liposome, 1 mg, 176
Perjeta J9306 Oncology pertuzumab, 1 mg, 178
Keytruda J9271 Oncology pembrolizumab, 1 mg, 168, V2
Portrazza J9295 Oncology necitumumab, 1 mg, 180
Polivy J9309 Oncology 179
Libtayo J9119 Oncology cemiplimab-rwlc, 1 mg, 172, V2

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Updated February 2020

Region

UCare Product

Eligibility

Service Area
(Minnesota Counties)

Narrow network?

North

UCare Medicare Plans (HMO-POS)

  • Essentials Rx
  • Total
  • Value
  • UCare Medicare Group Plans*
  • Must have Medicare Part A & Part B to enroll

    Do not have end-stage renal disease

    Aitkin, Becker, Beltrami, Carlton, Cass, Clay, Clearwater, Cook, Crow Wing, Douglas, Grant, Hubbard, Itasca, Kanabec, Kittson, Koochiching, Lake, Lake of the Woods, Mahnomen, Marshall, Morrison, Norman, Otter Tail, Pennington, Pine, Polk, Red Lake, Roseau, St. Louis, Todd, Wadena, Wilkin All UCare network providers
    North

    UCare Medicare Plans (HMO-POS)

  • Classic
  • Must have Medicare Part A & Part B

    Do not have end-stage renal disease

    Aitkin, Becker, Carlton, Cass, Clay, Cook, Crow Wing, Hubbard, Kanabec, Lake, Morrison, Pine and St. Louis All UCare network providers
    Metro

    UCare Medicare Plans (HMO-POS)

  • Prime
  • Essentials Rx
  • Complete
  • Classic
  • Total
  • Value
  • UCare Medicare Group Plans*
  • Must have Medicare Part A & Part B

    Do not have end-stage renal disease

    Anoka, Benton, Carver, Chisago, Dakota, Hennepin, Isanti, Mille Lacs, Ramsey, Scott, Sherburne, Stearns, Washington, Wright All UCare network providers
    South

    UCare Medicare Plans (HMO-POS)

  • Standard
  • Complete
  • Total
  • Value
  • UCare Medicare Group Plans*
  • Have Medicare Part A & Part B

    Do not have end-stage renal disease

    Big Stone, Blue Earth, Brown, Chippewa, Cottonwood, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Jackson, Kandiyohi, Lac qui Parle, Le Sueur, Lincoln, Lyon, Martin, McLeod, Meeker, Mower, Murray, Nicollet, Nobles, Olmsted, Pipestone, Pope, Redwood, Renville, Rice, Rock, Sibley, Steele, Stevens, Swift, Traverse, Wabasha, Waseca, Watonwan, Winona, Yellow Medicine All UCare network providers
    South

    UCare Medicare Plans (HMO-POS)

  • Classic
  • Have Medicare Part A & Part B

    Do not have end-stage renal disease

    Blue Earth, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Le Sueur, Mower, Nicollet, Olmsted, Rice, Steele, Wabasha, Waseca, Watonwan, Winona All UCare network providers

    In-Network Services

    Primary Care Office Visits $0 copay $25 copay $0 copay $20 copay $0 copay $0 copay $0 copay
    Specialist Office Visits $35 copay $50 copay $20 copay $45 copay $40 copay $10 copay $35 copay
    Inpatient Hospital Care $400 copay per stay (not per day), then 100% coverage, unlimited days per admission $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission $250 copay per stay (not per day), then 100% coverage, unlimited days per admission $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission $500 copay per day (days 1 - 3), then 100% coverage, unlimited days per admission $100 copay per stay (not per day), then 100% coverage, unlimited days per admission $150 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission
    Urgent Care $50 copay $45 copay $50 copay $50 copay $40 copay $0 copay $50 copay
    Worldwide Emergency Care $100 copay $90 copay $100 copay $100 copay $90 copay $100 copay $100 copay
    Medicare Part D Prescription Drug Coverage* No Prescription Drug Coverage $400 deductible | Copays based on drug tiers $200 deductible | Copays based on drug tiers $400 deductible | Copays based on drug tiers $400 deductible | Copays based on drug tiers Copays based on drug tiers $200 deductible | Copays based on drug tiers
    Preventive Dental Coverage Yes No Yes Yes Yes No No
    Vision Coverage-Routine Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: Not Covered Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay
    Vision Coverage-Diagnostic Diagnostic Eye Exam: $35 copay Diagnostic Eye Exam: $50 copay Diagnostic Eye Exam: $20 copay Diagnostic Eye Exam: $45 copay Diagnostic Eye Exam: $40 copay Diagnostic Eye Exam: $10 copay Diagnostic Eye Exam: $35 copay
    Hearing Services-Routine Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: Not Covered Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay; $500 allowed every 36 months for hearing aids Routine Hearing Exam: 1 per year, $0 Copay
    Hearing Services-Diagnostic Diagnostic Hearing Exam: $35 copay Diagnostic Hearing Exam: $50 copay Diagnostic Hearing Exam: $20 copay Diagnostic Hearing Exam: $45 copay Diagnostic Hearing Exam: $40 copay Diagnostic Hearing Exam: $10 copay Diagnostic Hearing Exam: $35 copay
    Out of Pocket Maximum $3,400 $5,000 $3,400 $3,400 $4,500 $3,000 $3,000

     

    * Part D deductible only applies to some drugs. See the Drug Formulary for details. 

    Pharmacy benefit information