2021 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.

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
Opdivo - Medicare J9299 Oncology nivolumab, 1 mg, 177B, V2
Oxlumo J0224 Rare/Misc Conditions 239, Oxlumo, J0224, 3mg, rare
Danyelza J9348 Oncology 242, Oncology, Danyelza, itamab-gqgk injection, J9348
Haegarda J0599 Hereditary Angioedema 127, Haegarda, Hereditary Angioedema
Panhematin J1640 Hematology/Biosimilar 240, Hematology/Biosimilar, Panhematin, hemin injection for intravenous infusion, J1640
Revcovi NOC Enzyme Replacement Not Otherwise Classified, 116, V2
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
Scenesse NOC Rare/Misc Conditions 226, famelanotide implant for subcutaneous use
Unituxin NOC Oncology 241, Unituxin, dinutuximab injection, NOC, Oncology,
Fasenra J0517 Immunologicals benralizumab, 1 mg, 118
Yescarta Q2041 Oncology 189, Q2041, axicabtagene ciloleucel suspension for intravenous infusion, Kite Pharma
Adakveo J0791 Hematology crizanlizumab-tmca injection, for intravenous use. 220
Enhertu J9358 Oncology fam-trastuzumab deruxtecan-nxki injection for intravenous use, 223
Reblozyl J0896 Hematology luspatercept-aamt for subcutaneous injection, 221
Phesgo NOC Oncology pertuzumab, trastuzumab, hyaluronidase-zzxf, 230
Herceptin Q5113 Oncology/Biosimilar 212, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg
Herzuma Q5113 Oncology/Biosimilar 212, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg
Padcev J9177 Oncology enfortumab vedotin – ejfv injection for intravenous use, 224
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
Vectibix J9303 Oncology panitumumab, 10 mg, 186
Uplinza NOC Rare/Misc Conditions inebilizumab-cdon, 232,
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
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
Rituxan - Medicaid, IFP J9312 Oncology rituximab, 100 mg, 216A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Ogivri Q5114 Oncology/Biosimilar 212, trastuzumab-dkst, biosimilar, (ogivri), 10 mg
Darzalex Faspro J9144 Oncology daratumumab 10 mg and hyaluronidase-fihj, 234
Ontruzant Q5112 Oncology/Biosimilar 212, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg
Azedra (Diagnostic & Therapeutic) A9590 Oncology Iodine i-131 iobenguane, diagnostic, therapeutic, 1 millicurie, 197, 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
Vyepti J3032 Rare/Misc Conditions mitomycin pyelocalyceal instillation, 1 mg, 235
Jelmyto J9281 Oncology mitomycin pyelocalyceal instillation, 1 mg, 236
Trodelvy J9317 Oncology sacituzumab govitecan-hziy, 10 mg, 237
Zolgensma J3399 Rare/Misc Conditions Not Otherwise Classified, 198
Ultomiris J1303 Rare/Misc Conditions emapalumab-lzsg, 1 mg, 199, V2
Xiaflex J0775 Rare/Misc Conditions collagenase, clostridium histolyticum, 0.01 mg, 200
Xolair - Medicaid, IFP J2357 Immunologicals omalizumab, 5 mg, 132A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Stelara (Subcutaneous) J3357 Inflammatory Conditions Ustekinumab, for subcutaneous injection, 1 mg, 201
Breyanzi - Medicaid, IFP C9076 Oncology 246A, Breyanzi, lisocabtagene maraleucel suspension for intravenous infusion, C9076
Ilaris J0638 Inflammatory Conditions canakinumab, 1 mg, 202
Ilumya J3245 Inflammatory Conditions tildrakizumab, 1 mg, 203
Tremfya J1628 Inflammatory Conditions guselkumab, 1 mg, 208
Rituxan Hycela J9311 Oncology rituximab 10 mg and hyaluronidase, 209, V2
Neulastae - Medicaid,IFP J2505 Hematology/Biosimilar 213A, pegfilgrastim, 6 mg, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Procrit J0885 Hematology epoetin alfa, (for non-esrd use), 1000 units, 211
Dupixent - Medicaid, IFP NOC Immunologicals dupilumab subcutaneous injection, 217, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
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
Cinqair J2786 Immunologicals reslizumab, 1 mg, 106, V2
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
Riabni - Medicare Q5123 Oncology/Biosimilar rituximab-arrx for intravenous use
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
Xolair - Medicare J2357 Immunologicals omalizumab, 5 mg, 132B
Aralast NP J0256 Rare/Misc Conditions alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg, 101
Breyanzi - Medicare C9076 Oncology 246B, Breyanzi, lisocabtagene maraleucel suspension for intravenous infusion, C9076
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
Cablivi C9047 Hematology caplacizumab-yhdp, 1 mg, 124, V2
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
Erbitux J9055 Oncology J9055, cetuximab, 10 mg
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
Rituxan - Medicare J9312 Oncology rituximab, 100 mg, 216B, V2
Soliris - Medicare J1300 Rare/Misc Conditions eculizumab, 10 mg, 194B, V2
Stelara (intravenous) J3358 Inflammatory Conditions Ustekinumab, for intravenous injection, 1 mg, V2
Renflexis - Medicare Q5104 Inflammatory Conditions/Biosimilar 215B, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with MHealth Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare), infliximab-abda, biosimilar, (renflexis), 10 mg
Tecentriq J9022 Oncology atezolizumab, 10 mg, 185, V2
Abecma - Medicare NOC Oncology 250B, NOC, idecabtagene vicleucel injection – Bristol-Myers Squibb and bluebird bio), CAR-T
Kymriah - Medicare Q2042 Oncology Tisagenlecleucel, up to 600 million car-positive viable t cells, 169B, Medicare
Zaltrap J9400 Oncology ziv-aflibercept, 1 mg, 190
Luxturna J3398 Rare/Misc Conditions voretigene neparvovec-rzyl, 1 billion vector genomes, 191
Lutathera A9513 Ophthalmology voretigene neparvovec-rzyl, 1 billion vector genomes 191
Spinraza J2326 Rare/Misc Conditions nusinersen, 0.1 mg, 196, V2
Soliris - Medicaid, IFP J1300 Rare/Misc Conditions eculizumab, 10 mg, 194A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Onpattro J0222 Rare/Misc Conditions patisiran, 0.1 mg, 102, V2
Tegsedi NOC Rare/Misc Conditions Not Otherwise Classified, 103, V2
Neulasta - Medicare J2505 Hematology/Biosimilar 213B, pegfilgrastim, 6 mg, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with M Health Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare)
Fulphila - Medicare Q5108 Hematology/Biosimilar 213B, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with M Health Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare)
Nyvepria - Medicare NOC Hematology/Biosimilar 213B, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with M Health Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare)
Neupogen - Medicaid,IFP J1442 Hematology/Biosimilar 214B, Care Medicare Plans Only (UCare Medicare, UCare Medicare with M Health Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare), filgrastim (g-csf), excludes biosimilars, 1 microgram
Riabni - Medicaid, IFP Q5123 Oncology/Biosimilar rituximab-arrx for intravenous use
Nivestym - Medicare Q5110 Hematology/Biosimilar 214A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans), filgrastim-aafi, biosimilar, (nivestym), 1 microgram
Nivestym - Medicaid,IFP Q5110 Hematology/Biosimilar 214b, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with M Health Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare), filgrastim-aafi, biosimilar, (nivestym), 1 microgram
Renflexis - Medicaid,IFP Q5104 Inflammatory Conditions/Biosimilar 215A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans), infliximab-abda, biosimilar, (renflexis), 10 mg
Remicade - Medicaid,IFP J1745 Inflammatory Conditions/Biosimilar 215A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans), infliximab, excludes biosimilar, 10 mg
Remicade - Medicare J1745 Inflammatory Conditions/Biosimilar 215B, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with MHealth Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare), infliximab, excludes biosimilar, 10 mg
Avastin - Medicaid, IFP J9035 Oncology/Biosimilar 238A, bevacizumab, 10 mg, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Avastin - Medicare J9035 Oncology/Biosimilar 238A, bevacizumab, 10 mg, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with M Health Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare)
Kymriah - Medicaid, IFP Q2042 Oncology cetuximab, 10 mg 169A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Fulphila - Medicaid,IFP Q5108 Hematology/Biosimilar 213A, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Nyvepria - Medicaid,IFP NOC Hematology/Biosimilar 213A, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans)
Neupogen – Medicare J1442 Hematology/Biosimilar 214A, UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans), filgrastim (g-csf), excludes biosimilars, 1 microgram
Givlaari J0223 Rare/Misc Conditions givosiran injection solution, for subcutaneous use, 222
Pepaxto C9080 Oncology 252, C9080, melphalan flufenamide intravenous infusion – Oncopeptides
Nulibry C9080 Rare/Misc Conditions 251, NOC, fosdenopterin intravenous infusion – Origin Biosciences
Abecma - Medicaid, IFP NOC Oncology 250, NOC, idecabtagene vicleucel injection – Bristol-Myers Squibb and bluebird bio, CAR-T
Jevtana J9043 Oncology cabazitaxel, 1 mg, 166
Kadcyla J9354 Oncology ado-trastuzumab emtansine, 1 mg, 167
Keytruda J9271 Oncology pembrolizumab, 1 mg, 168, V2
Kyprolis J9047 Oncology carfilzomib, 1 mg, 170
Lartruvo J9285 Oncology olaratumab, 10 mg, 171
Libtayo J9119 Oncology cemiplimab-rwlc, 1 mg, 172, V2
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
Polivy J9309 Oncology 179
Portrazza J9295 Oncology necitumumab, 1 mg, 180
Evkeeza C9079 Rare/Misc Conditions 244, Rare/Misc Conditions, evinacumab-dgnb injection for intravenous use, C9079
Vyondys 53 J1429 Rare/Misc Conditions 219, Vyondys, 53, golodirsen intravenous infusion, Sarepta
Amondys 45 NOC Rare/Misc Conditions 245, Amondys, 45, casimersen intravenous infusion
Opdivo - Medicaid, IFP J9299 Oncology nivolumab, 1 mg, 177B, V2
Cosela C9078 Oncology Cosela, 247, trilaciclib injection for intravenous use, C9078
Margenza J9353 Oncology 248, Margenza, Oncology, margetuximab injection for intravenous use, J9353
Imcivree - Medicaid NOC Rare/Misc Conditions 249A, Imcivree, setmelanotide subcutaneous injection
Blenrep J9037 Oncology Belantamab mafodotin-blmf, 228
Monjuvi J9349 Oncology tafasitamab-cxix, 229
Zulresso J1632 Rare/Misc Conditions 193
Tepezza J3241 Rare/Misc Conditions 225, teprotumumab injection for intravenous use
Sarclisa J9227 Oncology 227, isatuximab-irfc injection, for intravenous use
Tecartus Q2053 Oncology brexucabtagene autoleucel, 231A, PMAP, Connect, MSC+, MnCare, all Individual and Family Plans, UCare Medicaid and Exchange Plans Only
Tecartus Q2053 Oncology brexucabtagene autoleucel, 231B, UCare Medicare Plans Only (UCare Medicare, UCare Medicare with M Health Fairview and North Memorial, EssentiaCare, Group Plans, MSHO, Connect + Medicare)
Viltepso J1427 Rare/Misc Conditions viltolarsen, 233
Spravato G2082, G2083 Rare/Misc Conditions Not Otherwise Classified, 192
Imcivree - Medicare, IFP NOC Rare/Misc Conditions 249B, Imcivree, setmelanotide subcutaneous injection