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Definitions
- Drug Name: Brand or Common Name of the HCPCS code
- Authorization Required: If there is a check mark in this column, then this medication requires authorization prior to administration
- Covered (No PA Required): If there is a check mark in this column, then there is No Authorization Required
- Not Covered: If there is a check mark in this column, then this HCPCS code is not a covered benefit
- Auth Required if Prescribed for an Oncology/Hematology Indication
- If there is a check mark in this column, the corresponding HCPCS code will require authorization if prescribed for an Oncology/Hematology ICD-10 diagnosis code found on the ICD-10 Codes listing.
- If not prescribed for an Oncology/Hematology Indication, the HCPCS Code is No Authorization Required.
- If there is a check mark in this column, the corresponding HCPCS code will require authorization if prescribed for an Oncology/Hematology ICD-10 diagnosis code found on the ICD-10 Codes listing.
- Medicaid Listing
- Medicaid Medical Pharmacy Benefit HCPCS
- Commercial Listing
- Commercial Medical Pharmacy Benefit HCPCS
- INTEGRITY (MMP) Listing
- Integrity (MMP) Medical Pharmacy Benefit HCPCS
- EFP (Extended Family Planning) Listing
- EFP Medical Pharmacy Benefit Covered HCPCS
- ICD-10 Codes Listing
- Listing of indications that require prior authorization for a designated HCPCS code that has a check mark in Auth Required if Prescribed for an Oncology/Hematology Indication.
- Medical Pharmacy Benefit Authorization Criteria
- Medicare Part B Step Therapy Document
Last Updated 1/13/2024
MEDICAIDINTEGRITY (MMP)CommercialEFP FormularyICD-10 Codes