Welcome to the Clinical Criteria Page
This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit.The effective dates for using these documents for clinical reviews are communicated through the provider notification process.
The Clinical Criteria information is alphabetized in the table below. You can also perform a search by entering any of the information from the table into the Search box.
Please note: Clinical criteria for orals or self-injectables can be found in our Searchable drug lists within the Drug List Search tab. Enter the name of the drug you're looking for, select the drug and dose you want and click on Clinical Criteria under the Notes & Restrictions section.
For commercial plan members using our Medical Specialty Precertification Drug List, precertification is required for certain medical specialty drugs. Choose your plan below for a complete list of medical specialty drugs requiring clinical review by CarelonRx.
Medical Specialty Precertification Drug List | Medical Specialty Precertification Drug List.pdf
With our Site of Care program, certain specialty drugs when covered under the medical benefit require additional clinical review under CarelonRx’s clinical utilization management guidelines. Request for use of outpatient infusion or injectable therapy service in the hospital outpatient department or hospital outpatient clinic will be reviewed for medical necessity. Choose your plan for a complete list of drugs requiring site of care review.
Site of Care Drug List | Site of Care Drug List.pdf
Development of clinical criteria
All clinical criteria are developed to help guide clinically appropriate use of drugs and therapies and are reviewed and approved by the CarelonRx* Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an independent and external committee including practicing physicians, pharmacists, and clinicians from leading academic medical centers and clinical practices with expertise in evidence-based medicine. All major clinical specialties are represented.
If you have questions or feedback, please contact druglist@carelon.com.
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| Abecma (idecabtagene vicleucel) | CC-0195 | 0537T, 0538T, 0539T, 0540T, C9081, J3490, J3590, J9999, Q2055 | |
| Abraxane (paclitaxel, protein bound) | CC-0099 | J9264 | |
| Actimmune (interferon gamma-1b) | CC-0085 | J9216 | |
| Adakveo (crizanlizumab) | CC-0153 | J0791 | |
| Aduhelm (aducanumab) | CC-0200 | J0172 | |
| Adzynma (ADAMTS13, recombinant-krhn) | CC-0252 | J7171 | |
| Aphexda (motixafortide) | CC-0253 | J2277 | |
| Givlaari (givosiran) | CC-0154 | J0223 | |
| Adcetris (brentuximab vedotin) | CC-0092 | J9042 | |
| Leqembi (lecanemab) | CC-0228 | J0174 | |
| Sunlenca (lenacapavir) | CC-0229 | J1961 | |
| Agents for Hemophilia A and von Willebrand Disease | Antihemophilic Factor (Human) [Hemofil-M, Koate/Koate-DVI]. Antihemophilic Factor (Recombinant) [Advate, Afstyla, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha/Xyntha Solofuse]. Antihemophilic Factor (Recombinat [Pegylated]) [Adynovate, Jivi]. Antihemophilic Factor (Recombinat Fc Fusion Protein) - Eloctate. Antihemophilic Factor (Recombinat Glycopegylated) - Esperoct. Antihemophilic Factor (Recominat Fc-VWF-XTEN Fusion Protein-ehtl) - Altuviiio. Antihemophilic Factor (bispecific) [Hemlibra (emicizumab-kxwh)]. Antihemophilic Factor (Recombinant [Porcine Sequence]) [Obizur]. Antihemophilic Factor/von Willebrand Factor Complex (Human) [Alphanate, Humate-P, Wilate]. von Willebrand factor (Recombinant) [Vonvendi]. | CC-0065 | J7190, J7182, J7185, J7192, J7204, J7209, J7210, J7211, J7205, J7207, J7208, J7214, J7188, J7191, J7183, J7186, J7187, J7179, J7170 |
| Agents for Hemophilia B | Factor IX (Human) [Alphanine SD, Mononine. Factor IX Complex (Human) [(Factors II, IX, X)] [Profilnine SD]. Factor IX (Recombinant) [Benefix, Ixinity, Rixubis]. Factor IX (Recombinant [Albumin Fusion Protein]) [Idelvion]. Factor IX (Recombinant [Fc Fusion Protein]) [Alprolix]. Factor IX (Recombinant [Glycopegylated]) [Rebinyn]. | CC-0148 | J7193, J7194, J7195, J7200 J7201, J7202, J7203, J7213 |
| Iron Agents | Feraheme (ferumoxytol), Ferrlecit (sodium ferric gluconate/sucrose complex), Infed (iron dextran), Injectafer (ferric carboxymaltose), Monoferric (ferric derisomaltose), Triferic/Triferic AVNU (ferric pyrophosphate citrate), Venofer (iron sucrose) | CC-0182 | J1443, J1445, J1437, Q0138, J2916, J1750, J1756, J1439 |
| Akynzeo (fosnetupitant and palonosetron) for Iinjection | CC-0074 | J1454 | |
| Aldurazyme (laronidase) | CC-0025 | J1931, S9357 | |
| Aliqopa (copanlisib) | CC-0133 | J9057 | |
| Amtagvi (lifleucel) | CC-0259 | J3490, J3590 | |
| Amondys 45 (casimersen) | CC-0189 | J1426 | |
| Anktiva (nogapendekin alfa inbekicept-pmln) | CC-0264 | J9028 | |
| Alpha-1 Proteinase Inhibitor Therapy | Aralast, Glassia, Prolastin-C, Zemaira | CC-0073 | J0256, J0257 |
| Aristada Initio (aripiprazole lauroxil) | CC-0083 | J1943 | |
| Arzerra (ofatumumab) | CC-0122 | J9302 | |
| Asparagine Specific Enzymes | Asparlas (calaspargase pegol-mknl), Oncaspar (pegaspargase), Erwinaze (asparaginase [erwinia chrysanthemi]) , Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) | CC-0096 | J9019, J9020, J9021, J9266, J9118 |
| Aucatzyl (obecabtagene autoleucel) | CC-0272 | C9399, J9999 | |
| Bavencio (avelumab) | CC-0129 | J9023 | |
| Beleodaq (belinostat) | CC-0176 | J9032 | |
| Bendamustine Agents | Belrapzo, Bendeka, Treanda, Vivimusta | CC-0116 | J9036, J9033, J9034, J9056, J9058, J9059 |
| Benlysta (belimumab) | CC-0028 | J0490 | |
| Besponsa (inotuzumab ozogamicin) | CC-0131 | J9229 | |
| BESREMi (ropeginterferon alfa-2b-njft) | CC-0206 | J3490, J3590, J9999, C9399 | |
| Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis | Avonex (interferon beta-1a), Plegridy (peginterferon beta-1a), Rebif (interferon beta-1a), Betaseron (interferon beta-1b), Extavia (interferon beta-1b), Copaxone (glatiramer acetate), Glatopa (glatiramer acetate) | CC-0014 | C9399, J1595, J1826, J1830, J3490, Q3027, Q3028, S9559 |
| Bevacizumab for Non-ophthalmologic Indications | Avastin, Alymsys, Avzivi, Mvasi, Vegzelma, Zirabev | CC-0107 | J3490, J3590, J9035, Q5107, Q5118, Q5126, Q5129 |
| Beyfortus (nirsevimab) | CC-0247 | 90380, 90381, 96380, 96381 | |
| Blincyto (blinatumomab) | CC-0126 | J9039 | |
| Botulinum Toxin | Botox (OnabotulinumtoxinA), Daxxify (daxibotulinumtoxinA-lanm), Xeomin (IncobotulinumtoxinA), Dysport (AbobotulinumtoxinA), Myobloc (RimabotulinumtoxinB) | CC-0032 | 31573, 46505, 52287, 64647, 67345, 46505, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, J0585, J0586, J0587, J0588, J0589, S2340, S2341 |
| Breyanzi (lisocabtagene maraleucel) | CC-0187 | Q2054 | |
| Brineura (cerliponase alfa) | CC-0012 | J0567 | |
| Cabenuva (cabotegravir extended-release; rilpivirine extended-release) injection | CC-0194 | J0741 | |
| Cablivi (caplacizumab-yhdp) | CC-0137 | J3590, C9047 | |
| Colony Stimulating Factor Agents | Elfapegrastim agents (Rolvedon). Elbemalenograstim agents (Ryzneuta). Filgrastim agents (Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta/Neulasta Onpro, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca/Udenyca Onbody, Ziextenzo). Sargramostim agents (Leukine, Prokine). | CC-0002 | 96377, C9173, J3590, J1442, J1447, J1449, J2506, J2820, J9361, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5127, Q5130 |
| Columvi (glofitamab-gxbm) | CC-0244 | J9286 | |
| Cosela (trilaciclib) | CC-0192 | J1448 | |
| Complement C5 Inhibitors | Epysqli (eculizumab-aagh), Piasky (crovalimab-akkz), Soliris (eculizumab), Ultomiris (ravulizumab-cwvz) | CC-0041 | J1300, J1303, J1307, J3590, Q5139 |
| Crysvita (burosumab-twza) | CC-0081 | J0584 | |
| Cyramza (ramucirumab) | CC-0123 | J9308 | |
| Danyelza (naxitamab-gqgk) | CC-0184 | J9348 | |
| Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj) | CC-0127 | J9145, J9144 |
| Denosumab agents | Prolia, Jubbonti, Xgeva, Wyost | CC-0027 | J0897, J3590, Q5136 |
| Dihydroergotamine (DHE) injection | CC-0052 | J1110 | |
| Docetaxel | Taxotere | CC-0093 | J9171, J9172 |
| Doxorubicin liposome | Doxil | CC-0098 | Q2050 |
| Drug dosage, frequency, and route of administration | CC-0136 | ||
| Duopa (carbidopa and levodopa enteral suspension) | CC-0035 | J7340 | |
| Dupixent (dupilumab) | CC-0029 | C9399, J3590 | |
| Durysta (bimatoprost implant) | CC-0163 | J7351 | |
| Egrifta (tesamorelin) | CC-0069 | J3490, J3590 | |
| Elaprase (idursulfase) | CC-0024 | J1743, S9357 | |
| Elzonris (tagraxofusp-erzs) | CC-0088 | J9269 | |
| Empaveli (pegcetacoplan) | CC-0199 | J3490, C9399 | |
| Empliciti (elotuzumab) | CC-0117 | J9176 | |
| Enhertu (fam-trastuzumab deruxtecan-nxki) | CC-0158 | J9358 | |
| Enjaymo (sutimlimab-jome) | CC-0210 | J1302 | |
| Enspryng (satralizumab-mwge) | CC-0173 | J3490, J3590, C9399 | |
| Entyvio (vedolizumab) | CC-0071 | J3380, J3590 | |
| Enzyme Replacement Therapy for Gaucher Disease | Cerezyme (imiglucerase), Elelyso (taliglucerase), Vpriv (velaglucerase) | CC-0051 | J1786, J3060, J3385, S9357 |
| Erbitux (cetuximab) | CC-0106 | J9055 | |
| Erythropoiesis Stimulating Agents | Aranesp (darbepoetin alfa), Epogen (epoetin alfa), Mircera (methoxy polyethylene glycol-epoetin beta), Procrit (epoetin alfa), Retacrit (epoetin alfa-epbx) | CC-0001 | J0881, J0882, J0885, Q4081, J0887, J0888, Q4081, Q5105, Q5106
, EA, EB EC |
| Spevigo (spesolimab-sbzo) | CC-0221 | J1747 | |
| Xenpozyme (olipudase alfa) | CC-0220 | J0218 | |
| Evenity (romosozumab-aqqg) | CC-0139 | J3111 | |
| Evkeeza (evinacumab) | CC-0193 | J1305 | |
| Exondys 51 (eteplirsen) | CC-0044 | J1428 | |
| Ethyol (amifostine) | CC-0155 | J0207 | |
| Fabrazyme (agalsidase beta) | CC-0021 | J0180, S9357 | |
| Faslodex (fulvestrant) | CC-0103 | J9393, J9394, J9395 | |
| Fuzeon (enfuvirtide) | CC-0055 | J1324 | |
| Fyarro (sirolimus albumin bound) | CC-0205 | J9331 | |
| GamaSTAN [(immune globulin (human)] | GamaSTAN, GamaSTAN S/D | CC-0039 | 90281, J1460, J1560, |
| Gamifant | CC-0087 | J9210 | |
| Gazyva (obinutuzumab) | CC-0121 | J9301 | |
| Gonadotropin Releasing Hormone Analogs for oncologic indications | Camcevi (leuprolide mesylate), Firmagon (degarelix), Zoladex (goserelin acetate), Eligard (leuprolide acetate), Lupron Depot (leuprolide acetate), and Trelstar, Trelstar LA (triptorelin pamoate) | CC-0102 | J1950, J9202, J9218, S9560, J3315, J9155, J9217, J9225, J1675, J1950, J3315, J9155, J9202, J1952 |
| Elahere (mirvetuximab) | CC-0226 | J9063 | |
| Gonadotropin Releasing Hormone Analogs for the treatment of non-oncologic indications | Fensolvi (leuprolide acetate), Zoladex (goserelin acetate), Supprelin LA (histrelin acetate), Lupron Depot/Depot-Ped (leuprolide acetate), Synarel Nasal Spray (nafarelin acetate), Triptodur (triptorelin pamoate extended-release) | CC-0061 | J1675, J3316, J9202, J9226, S9560, J1950, J1951, J9217, J9218, J1954 |
| Growth hormone | Somatropin: Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive; Somapacitan-beco: Sogroya; Lonapegsomatropin-tcgd: Skytrofa | CC-0068 | J2940, J2941, S9558, J3490, J3590, C9399 |
| Repository Corticotropin Injection | Acthar Gel, Purified Cortrophin Gel | CC-0004 | J0801, J0802 |
| Halaven (eribulin) | CC-0108 | J9179 | |
| Hereditary Angioedema Agents | Cinryze, Haegarda, Berinert: [C1 Inhibitor (Human)], Ruconest [C1 Inhibitor (Recombinant)], Takhzyro (lanadelumab-flyo), Icatibant (Firazyr, Sajazir), Kalbitor (ecallantide) | CC-0034 | J0593, J0596, J0597, J0598, J1290, J1744, J0599 |
| Human Parathyroid Hormone | Bonsity, (teriparatide), Forteo (teriparatide),Tymlos (abaloparatide) | CC-0038 | J3490, C9399, J3110 |
| Hyaluronan Injections | Durolane, Euflexxa, Gel-One, Gel-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synojoynt, Synvisc/-One, Triluron, TriVisc, Visco-3 | CC-0006 | J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332 |
| Hyaluronan Injections - Step Therapy and Quantity Limit - MEDICARE ONLY | Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3 | CC-0005 | J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329 , J7331, J7332 |
| Imdelltra (tarlatamab-dlle) | CC-0263 | J9026 | |
| iDoseTR (travoprost implant) | CC-0258 | J7355 | |
| Imcivree (setmelanotide) | CC-0188 | J3590, C9399 | |
| Imfinzi (durvalumab) | CC-0130 | J9173 | |
| Imjudo (tremelimumab-actl) | CC-0223 | J9347 | |
| Immunoglobulins | Immune Globulin: Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify, Yimmugo | CC-0003 | 90283, 90284, J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1599, J3590, S9338 |
| Increlex (mecasermin) | CC-0045 | J2170 | |
| Infertility Agents and HCG Agents | Menopur (menotropins), Follistim AQ (follitropin beta), Gonal-f/RFF (follitropin beta), Pregnyl, Novarel: Chorionic Gonadotropin (Human), Ovidrel (Chorionic Gonadotropin (Recombinant), Cetrotide (cetrorelix), Ganirelix, Lupron Depot (leuprolide acetate), Crinone 8% gel, Endometrin vaginal insert, progesterone | CC-0015 | J9217, J0725, J1950, J3490, J8499, S0122, S0126, S0128, S0132 |
| Hydroxyprogesterone-caproate | CC-0238 | J1729 |
|
| Qalsody (tofersen) | CC-0237 | J1304 |
|
| Interleukin-1 Inhibitors | Arcalyst (rilonacept), Ilaris (canakinumab,; Kineret (anakinra) | CC-0064 | J2793, J0638, J3590, C9399 |
| Intravitreal Corticosteroid Implants | Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant) | CC-0031 | J7314, 67027, J7311, 08H033Z, 08H133Z, 67028, J7313, 67028, J7312 |
| Istodax (romidepsin) | Istodax | CC-0100 | J9318, J9319 |
| Ixempra (ixabepilone) | CC-0090 | J9207 | |
| Izervay (avacincaptad pegol) | CC-0245 | J2782 | |
| Jelmyto (mitomycin) | CC-0164 | J9281 | |
| Jemperli (dostarlimab-gxly) | CC-0197 | J9272 | |
| Jevtana (cabazitaxel) | CC-0114 | J9043, J9064 | |
| Kadcyla (ado-trastuzumab) | CC-0115 | J9354 | |
| Kanuma (sebelipase alfa) | CC-0037 | J2840 |
|
| Kesimpta (ofatumumab) | CC-0174 | J3490, J3590, C9399 |
|
| Keytruda (pembrolizumab) | CC-0124 | J9271 | |
| Kimmtrak (tebentafusp-tebn) | CC-0211 | J9274 | |
| Krystexxa (pegloticase) | CC-0057 | J2507 |
|
| Kymriah (tisagenlecleucel) | CC-0150 | 0537T, 0538T, 0539T, 0540T, Q2042
|
|
| Kyprolis (carfilzomib) | CC-0120 | J9047 | |
| Lemtrada (alemtuzumab) for Treatment of Multiple Sclerosis | CC-0009 | J0202 |
|
| Levoleucovorin Agents | Fusilev, Khapzory | CC-0104 | J0641, J0642 |
| Libtayo (cemiplimab-rwlc) | CC-0145 | J9119 | |
| Loqtorzi (toripalimab-tpzi) | CC-0255 | J3263 | |
| Lumoxiti (moxetumomab pasudotox-tdfk) | CC-0144 | J9313 | |
| Melanoma Vaccines | Imlygic (talimogene laherparepvec), other melanoma vaccines | CC-0135 | J9325, J3590 |
| Margenza (margetuximab-cmkb) | CC-0186 | J9353 | |
| Mepsevii (vestronidase alfa) | CC-0013 | J3397 | |
| Adstiladrin (nadofaragene firadenovec-vncg) | CC-0230 | J9029 | |
| Lamzede (velmanase alfa-tycv) | CC-0231 | J0217 | |
| Lunsumio (mosunetuzumab-axgb) | CC-0232 | J9350 | |
| Rebyota (fecal microbiota, live – jslm) | CC-0233 | J1440 | |
| Syfovre (pegcetacoplan) | CC-0234 | J2781 | |
| Monjuvi (tafasitamab-cxix) | CC-0180 | J9349 | |
| Monoclonal Antibodies to Interleukin-17 | Bimzelx (bimekizumab-bkzx), Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab) | CC-0042 | C9399, J3490, J3590, J3247 |
| Monoclonal Antibodies to Interleukin-23 | Ilumya (tildrakizumab-asmn), Omvoh (mirikizumab-mrkz), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab) | CC-0050 | J1628, J3245, J2327, J2267 |
| Monoclonal Antibodies to Interleukin-5 | Cinqair (reslizumba), Fasenra (benralizumab), Nucala (mepolizumab) | CC-0043 | J0517, J2182, J2786 |
| Monoclonal Antibodies to Interleukin-6 | Actemra (tocilizumab), Tofidence (tocilizumab-bavi), Tyenne (tocilizumab-aazg), Kevzara (sarilumab) | CC-0066 | J3262, C9399, J3490, J3590, Q5133, Q0249 |
| Mozobil (plerixafor) | CC-0089 | J2562 | |
| Mylotarg (gemtuzumab ozogamicin) | CC-0132 | J9203 | |
| Naglazyme (galsulfase) | CC-0023 | J1458, S9357 | |
| Naltrexone Implantable Pellets | CC-0036 | 11981, 11983, 17999, 22999, 49999, J3490, J7999 | |
| Nexobrid (anacaulase-bcdb) | CC-0260 | J7353 | |
| Nplate (romiplostim) | CC-0111 | J2802 | |
| Nulibry (fosdenopterin) | CC-0190 | J3490, J3590, C9399 | |
| Nulojix (belatacept) | CC-0076 | J0485 | |
| Ocrevus (ocrelizumab) | CC-0011 | J2350 | |
| Rytelo (imetelstat) | CC-0266 | J0870 | |
| Octreotide Agents | Bynfezia, Sandostatin, Sandostatin LAR Depot | CC-0058 | J2353, J2354 |
| Off Label Drug and Approved Orphan Drug Use | CC-0141 | ||
| Onpattro (patisiran) | CC-0082 | J0222 | |
| Opdivo (nivolumab) | CC-0125 | J9299 | |
| Orencia (abatacept) | CC-0078 | J0129 | |
| Oxlumo (lumasiran) | CC-0185 | J0224 | |
| Padcev (enfortumab vedotin-ejfv) | CC-0157 | J9177 | |
| Palynziq (pegvaliase-pqpz) | CC-0077 | C9399, J3590 | |
| Pedmark (sodium thiosulfate injection) | CC-0224 | J0208 | |
| Pemetrexed Agents | Alimta, Pemfexy, Pemrydi | CC-0094 | J9304, J9305, J9314, J9322, J9323, J9324, J9292, J9294, J9296, J9297 |
| Kisunla (donanemab-azbt) | CC-0265 | J0175 | |
| Perjeta (pertuzumab) | CC-0110 | J9306 | |
| Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) | CC-0169 | J9316 | |
| Polivy (polatuzumab vedotin-piiq) | CC-0143 | J9309 | |
| Prialt (ziconotide) | CC-0040 | J2278 | |
| Revcovi (elapegademase-lvlr) | CC-0235 | J3590, C9399 | |
| Signifor LAR (pasireotide) | CC-0236 | J2502 | |
| Proleukin (aldesleukin) | CC-0175 | J9015 | |
| Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors | Praluent (alirocumab), Repatha (evolocumab) | CC-0010 | C9399, J3490, J3590 |
| Prostacyclin Infusion and Inhalation Therapy | Flolan (epoprostenol), Remodulin (treprostinil), Tyvaso (treprostinil), Veletri (epoprostenol), Ventavis (iloprost) | CC-0067 | J1325, J3285, J7686, K0455, Q4074, S0155, S9347 |
| Provenge (sipuleucel-T) | CC-0134 | Q2043 | |
| Radicava (edaravone) | CC-0049 | C9399, J1301, J8499 | |
| Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy | Azedra (iobenguane I 131), Lutathera (lutetium Lu 177 dotatate), Pluvicto (lutetium Lu 177), Zevalin (ibritumomab tiuxetan) | CC-0118 | A9543, 79403, 79101, A9513, A9590, A9607 |
| Reblozyl (luspatercept) | CC-0156 | J0896 | |
| Relizorb (immobilized lipase) cartridge | CC-0198 | B4105 | |
| Rituximab agents for Non-Oncologic Indications | Rituxan, Riabni, Ruxience, Truxima | CC-0075 | J9312, Q5115, Q5119, Q5123 |
| Rituximab agents for Oncologic Indications | Rituxan, Riabni, Ruxience, Truxima | CC-0167 | J9312, Q5115, Q5119, Q5123 |
| Rivfloza (nedosiran) | CC-0256 | J3490 | |
| Sarclisa (isatuximab-irfc) | CC-0161 | J9227 | |
| Selected Injectable 5HT3 Antiemetic Agents | Aloxi injection (palonosetron) | CC-0056 | J2469 |
| Selected Injectable NK-1 Antiemetic Agents | Cinvanti injection (aprepitant), Emend injection (fosaprepitant), Focinvez (fosaprepitant) | CC-0059 | J1453, J1456, J0185, C9145, J3490 |
| Vascular Endothelial Growth Factor (VEGF) Inhibitors | Avastin, Alymsys, Mvasi, Vegzelma, Zirabev (bevacizumab, bevacizumab-maly, bevacizumab-awwb, bevacizumab-bvzr, bevacizumab-adcd), Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-cqrn), Eylea (aflibercept), Eylea HD (aflibercept), Beovu (brolucizumab-dbll), Vabysmo (faricimab-svoa) | CC-0072 | Q5118, C9257, J9035, Q5107, J2778, J0177, J0178, J0179, Q5124, J2777, Q5126, Q5128, Q5129 |
| Vyloy (zolbetuximab-clzb) | CC-0273 | C9399, J9999 | |
| Scenesse (afamelanotide) | CC-0159 | J7352 | |
| Spinraza (nusinersen) | CC-0048 | 96450, J2326 | |
| Spravato (esketamine) | CC-0086 | G2082, G2083, S0013 | |
| Ustekinumab | Stelara (ustekinumab), Imuldosa (ustekinumab-srlf), Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), Selarsdi (ustekinumab-aekn), Wezlana (ustekinumab-auub) | CC-0063 | J3357, J3358, J3590, Q5137, Q5138, Q9996, Q9997, Q9998 |
| Strensiq (asfotase alfa) | CC-0079 | J3490 | |
| Sylvant (siltuximab) | CC-0113 | J2860 | |
| Synagis (palivizumab) | CC-0007 | 90378, S9562 | |
| Synribo (omacetaxine mepesuccinate) | CC-0178 | J9262 | |
| Talvey (talquetamab-tgvs) | CC-0249 | J3055 | |
| Tecartus (brexucabtagene autoleucel) | CC-0168 | Q2053, 0537T, 0538T, 0539T, 0540T | |
| Tecentriq (atezolizumab) | CC-0128 | J9022 | |
| Tevimbra (tislelizumab-jsgr) | CC-0262 | J9329 | |
| Tecvayli (teclistamab-cqyv) | CC-0222 | J9380 | |
| Select Clotting Agents for Bleeding Disorders | FEIBA [Anti-inhibitor Coagulant Complex (Human)], Coagadex [Factor X (Human)], Novoseven RT, SevenFact [Factor VIIa (Recombinant)], Corifact [Factor XIII Concentrate (Human)], Tretten [Factor XIII A-Subunit (Recombinant)], RiaSTAP, Fibryga: [Fibrinogen Concentrate (Human)] | CC-0149 | J7198, J7189, J7175, J7180 , J7181, J7177, J7178, J7189, J7212 |
| Tegsedi (inotersen) | CC-0084 | J3490, C9399 | |
| Tepezza (teprotumumab-trbw) | CC-0162 | J3241 | |
| Tezspire (tezepelumab-ekko) | CC-0212 | J2356 | |
| Somatuline Depot (lanreotide) | CC-0142 | J1930, J1932 | |
| Subcutaneous Hormonal Implants | Testopel (testosterone), estrogen containing implants | CC-0008 | 11980, S0189, J3490 |
| Testosterone, Injectable | Depo-Testosterone (testosterone cypionate), Xyosted (testosterone enanthate), Aveed (testosterone undecanoate) | CC-0026 | J1071, J3121, J3145 |
| Torisel (temsirolimus) | CC-0101 | J9330 | |
| Trastuzumab Agents | Herceptin (trastuzumab), Hercessi (trastuzumab-strf), Herzuma (trastuzumab-pkrb), Kanjinti (trastuzumab-anns), Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), Trazimera (trastuzumab-qyyp), Herceptin Hylecta (trastuzumab; hyaluronidase-oysk) | CC-0166 | J9356, J9355, J3590, Q5113, Q5117 Q5114, Q5112, Q5116 |
| Trodelvy (sacituzumab govitecan) | CC-0165 | J9317 | |
| Trogarzo (ibalizumab-uiyk) | CC-0047 | J1746 | |
| Tumor Necrosis Factor Antagonists | Adalimumab agents (Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis, Zymfentra) | CC-0062 | J0139, J0717, J1438, J1602, J1745, J1748, J3490, J3590, Q5103, Q5104, Q5109, Q5121, Q5140, Q5141, Q5142, Q5143, Q5144, Q5145, S9359 |
| Natalizumab Agents | Tysabri (natalizumab), Tyruko (natalizumab-sztn) | CC-0020 | J2323, J3490, J3590 |
| Tzield (teplizumab-mzwv) | CC-0225 | J9381 | |
| Uplizna (inebilizumab-cdon) | CC-0170 | J1823 | |
| Vectibix (panitumumab) | CC-0105 | J9303 | |
| Velcade (bortezomib) | CC-0095 | J9041, J9044, J9046, J9048, J9049, J9051 | |
| Veopoz (pozelimab-bbfg) | CC-0250 | J9376 | |
| Vidaza (azacitidine) | CC-0097 | J9025 | |
| Viltepso (viltolarsen) | CC-0172 | J1427 | |
| Vimizim (elosulfase alfa) | CC-0022 | J1322, S9357 | |
| Voxzogo (vosoritide) | CC-0213 | J3490, C9399 | |
| Vyepti (eptinezumab) | CC-0160 | J3032 | |
| Vyondys 53 (golodirsen) | CC-0152 | J1429 | |
| Xiaflex (clostridial collagenase histolyticum) injection | CC-0017 | 20527, 26341, J0775 | |
| Xofigo (Radium Ra 223 Dichloride) | CC-0112 | A9606, 79101 | |
| Xolair (omalizumab) | CC-0033 | J2357 | |
| Ycanth (cantharidin) | CC-0251 | J7354 | |
| Yervoy (ipilimumab) | CC-0119 | J9228 | |
| Yescarta (axicabtagene ciloleucel) | CC-0151 | 0537T, 0538T, 0539T, 0540T, Q2041 | |
| Zaltrap (ziv-aflibercept) | CC-0109 | J9400 | |
| Zepzelca (lurbinectedin) | CC-0171 | J9223 | |
| Zilretta (triamcinolone acetonide extended-release) | CC-0177 | J3304 | |
| Zilbrysq (zilucoplan) | CC-0254 | J3490 | |
| Zinplava (bezlotoxumab) | CC-0046 | J0565 | |
| Zynyz (retifanlimab-dlwr) | CC-0240 | J9345 | |
| Elfabrio (pegunigalsidase alfa-iwxj) | CC-0241 | J2508 | |
| Elrexfio (elranatamab-bcmm) | CC-0248 | J1323 | |
| Epkinly (epcoritamab-bysp) | CC-0242 | J9321 | |
| Vyjuvek (beremagene geperpavec) | CC-0243 | J3401 | |
| Zoledronic Acid | Reclast, Zoledronic acid 4mg | CC-0019 | J3489 |
| Zulresso (brexanolone) | CC-0140 | J1632 | |
| Zynlonta (loncastuximab tesirine-lpyl) | CC-0196 | J9359 | |
| Rybrevant (amivantamab-vmjw) | CC-0201 | J9061 | |
| Ryplazim (plasminogen, human-tvmh) | CC-0203 | J2998 | |
| Rystiggo (rozanolixizumab-noli) | CC-0246 | J9333 | |
| Saphnelo (anifrolumab-fnia) | CC-0202 | J0491 | |
| Tivdak (tisotumab vedotin-tftv) | CC-0204 | J9273 | |
| Adbry (tralokinumab) | CC-0208 | J3490, J3590, C9399 | |
| Leqvio (inclisiran) | CC-0209 | J1306 | |
| Vyvgart (efgartigimod alfa-fcab), Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) | Vyvgart (efgartigimod alfa-fcab), Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) | CC-0207 | J9332, J9334 |
| Carvykti (ciltacabtagene autoleucel) | CC-0214 | Q2056 | |
| Opdualag (nivolumab and relatlimab-rmbw) | CC-0216 | J9298 | |
| Ketamine injection (Ketalar) | CC-0215 | J3490 | |
| Amvuttra (vutrisiran) | CC-0217 | J0225 | |
| Xipere (triamcinolone acetonide injectable suspension) | CC-0218 | 67516, J3299 | |
| Korsuva (difelikefalin acetate) | CC-0219 | J0879 | |
| Briumvi (ublituximab) | CC-0227 | J2329 | |
| Wainua (eplontersen) | CC-0257 | J3490, C9399 | |
| Pompe Disease | Lumizyme (alglucosidase alfa), Nexviazyme (avalglucosidase alfa-ngpt), Pombiliti (cipaglucosidase alfa-atga) | CC-0018 | J0219, J0221, J3490, J3590, S9357 |
| Winrevair (sotatercept-csrk) | CC-0261 | J3590, C9399 |
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