Adalimumab Injection

J0135

Benefit for clients 18 years of age or older

Diagnosis limitations: 5550, 5551, 5552, 5559, 6960, 7140, 7141, 7142, 7200

Azacitidine (Vidaza)

J9025

Benefit for clients 13 years of age or older

Diagnosis limitations: 20502, 20510, 20512, 20522, 20532, 20582, 20592, 23872, 23873, 23874, 23875, 2850

Certolizumab pegol

J0718

Diagnosis limitations: 5550, 5551, 5552, 5559, 7140, 7141, 7142, 71430, 71431, 71432, 71433

Cidofovir

J0740

N/A

Clofarabine (Clorar)

J9027

Prior authorization is required using the "CSHCN Services Program Authorization and Prior Authorization Request Form and Instructions" .

Documentation of the following must be submitted with the prior authorization request form:

•Refractory or relapsed acute lymphoblastic leukemia (diagnosis code 20400)

•At least 2 prior failed regimens

Dalteparin sodium

J1645

N/A

Denileukin Diftitox

J9160

Diagnosis limitations: 20210, 20211, 20212, 20213, 20214, 20215, 20216, 20217, 20218, 20220, 20270, 20271, 20272, 20273, 20274, 20275, 20276, 20277, 20278

Enoxaparin sodium

J1650

N/A

Epirubicin hydrochloride

J9178

Diagnosis limitations: 1740, 1741, 1742, 1743, 1744, 1745, 1746, 1748, 1749, 1750, 1759 (malignant neoplasm of male or female breast)

Epoprostenol

J1325

Diagnosis limitation: 4160 (primary pulmonary hypertension only)

Fondaparinux sodium

J1652

N/A

Granisetron hydrochloride

J1626

Diagnosis limitations: V580, V5811, V5812 (encounter of radiotherapy and chemotherapy diagnosis codes)

The quantity used must appear on the claim.

Ibutilide fumarate

J1742

Diagnosis limitations: 42731, 42732

Infliximab

J1745

Diagnosis limitations: 5550, 5551, 5552, 5559, 5651, 56981, 7140, 7141, 7142, 71430

Lioresal

J0475

J0476

Separate payment for the device is not a benefit for the physician or the hospital.

Natalizumab injection

J2323

Diagnosis limitations: 340, 5550, 5551, 5552, 5559

Porfimer sodium

J9600

Diagnosis limitations: 1500, 1501, 1502, 1503, 1504, 1505, 1508, 1509, 1978

Reclast

J3488

Diagnosis limitations: 7310, 73300, 73301, 73302, 73303, 73309, 73390

Rituximab

J9310

N/A

Sumatriptan succinate

J3030

Limited to treatment of classical migraines

Diagnosis limitation: 34600, 34602, 34603, 34612, 34613, 34622, 34623, 34630, 34631, 34632, 34633, 34640, 34641, 34642, 34643, 34650, 34651, 34652, 34653, 34660, 34661, 34662, 34663, 34670, 34671, 34672, 34673, 34682, 34683, 34692, 34693 (classical migraine without mention of intractable migraine)

Topotecan HCL

J9350

Diagnosis limitations: 1588, 1589, 1623, 1624, 1625, 1628, 1629, 1800, 1801, 1808, 1809, 1830, 1970, 1986, 19882

Trastuzumab

J9355

A benefit of the CSHCN Services Program as part of a treatment regimen containing doxorubicin, cyclophosphamide, and paclitaxel for the adjuvant treatment of clients with HER2 overexpressing, node positive breast cancer.

Diagnosis limitations: 1740, 1741, 1742, 1743, 1744, 1745, 1746, 1748, 1749, 1750, 1759

Valrubicin

J9357

Diagnosis limitation: 2337 (Carcinoma in situ of bladder)