[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288563-105":53,"doc-detail-288563-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","medical-injectables-prior-authorization-list-usfhp_2026_pc2575-effective-date-04152026","Medical Injectables Prior Authorization List - USFHP_2026_PC2575 - Effective Date 04/15/2026","","USFHP medical injectables are subject to medical-necessity prior authorization review, effective 04/15/2026, for all USFHP beneficiaries. Prior authorization requests must be submitted by completing the USFHP Prior Authorization Form and faxing it with all required clinical documentation to (800) 277-4926. The list includes HCPCS codes with code descriptions, drug names, and preferred biosimilars when applicable. Prior authorization does not guarantee coverage, eligibility, or payment for non-covered benefits.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medical-injectables-prior-authorization-list-usfhp_2026_pc2575-effective-date-04152026/288563/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medical-injectables-prior-authorization-list-usfhp_2026_pc2575-effective-date-04152026/288563.png","ImageObject",442,249,{"name":88,"@type":89},"Blitz","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"When do these USFHP prior authorization requirements take effect?","Question",{"text":108,"@type":109},"They take effect on 04/15/2026.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How must a prior authorization request be submitted?",{"text":113,"@type":109},"Complete the USFHP Prior Authorization Form and fax it with all required clinical documentation to (800) 277-4926.",{"name":115,"@type":106,"acceptedAnswer":116},"Does prior authorization guarantee coverage, eligibility, or payment?",{"text":117,"@type":109},"No. Prior authorization does not guarantee coverage, eligibility, or payment on non-covered benefits.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288563,1790161845,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},24464137899374,"https://us-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","| Effective Date 04/15/2026 Prior Auth Requirements applies to all USFHP beneficiaries All the Medical Injectables listed below are subject to medical necessity prior auth review |\n| --- |\n| Medical Injectables prior authorization requests must be submitted by completing the USFHP Prior Authorization Form and faxing the form with all required clinical documentation to Fax: (800) 277-4926 |\n| PRIOR AUTHORIZATION DOES NOT GUARANTEE COVERAGE OR ELIGIBILITY\u003Cbr>PRIOR AUTHORIZATION DOES NOT GUARANTEE PAYMENT ON NON-COVERED BENEFIT |\n\n\n| HCPCS CODE | CODE DESCRIPTION | DRUG NAME | PREFERRED BIOSIMILAR (IF APPLICABLE) |\n| --- | --- | --- | --- |\n| J0129 | ABATACEPT INJECTION | ORENCIA |  |\n| J0172 | INJ, ADUCANUMAB-AVWA, 2 MG | ADUHELM (DISCTON | INUED) |\n| J0174 | INJ, LECANEMAB-IRMB, 1 MG | LEQEMBI |  |\n| J0175 | INJ, DONANEMAB-AZBT, 2 MG | KISUNLA |  |\n| J0177 | INJ, AFLIBERCEPT HD, 1 MG | EYLEA HD |  |\n| J0180 | AGALSIDASE BETA INJECTION | FABRAZYME |  |\n| J0202 | INJECTION, ALEMTUZUMAB | LEMTRADA |  |\n| J0217 | INJ VELMANASEALFA-TYCV 1 MG | LAMZEDE |  |\n| J0218 | INJ OLIPUDASEALFA-RPCP 1MG | XENPOZYME |  |\n| J0219 | INJAVAL ALFA-NQPT 4MG | NEXVIAZYME |  |\n| J0221 | LUMIZYME INJECTION | LUMIZYME |  |\n| J0222 | INJ., PATISIRAN, 0.1 MG | ONPATTRO |  |\n| J0223 | INJ GIVOSIRAN 0.5 MG | GIVLAARI |  |\n| J0224 | INJ. LUMASIRAN, 0.5 MG | OXLUMO |  |\n| J0225 | INJ, VUTRISIRAN, 1 MG | AMVUTTRA |  |\n| J0256 | ALPHA 1 PROTEINASE INHIBITOR | PROLASTIN C |  |\n| J0257 | GLASSIA INJECTION | GLASSIA |  |\n| J0401 | INJ, ABILIFY MAINTENA, 1 MG | ABILIFY MAINTENA |  |\n| J0402 | INJ, ABILIFY ASIMTUFII, 1 MG | ABILIFY ASIMTUFII |  |\n| J0480 | BASILIXIMAB | SIMULECT |  |\n| J0485 | BELATACEPT INJECTION | NULOJIX |  |\n| J0490 | BELIMUMAB INJECTION | BENLYSTA |  |\n| J0491 | INJANIFROLUMAB-FNIA 1MG | SAPHNELO |  |\n| J0517 | INJ., BENRALIZUMAB, 1 MG | FASENRA |  |\n| J0565 | INJ, BEZLOTOXUMAB, 10 MG | ZINPLAVA |  |\n| J0584 | INJECTION, BUROSUMAB-TWZA 1M | CRYSVITA |  |\n| J0585 | BOTULINUM TOXIN TYPE A PER UNIT | BOTOX |  |\n| J0586 | ABOBOTULINUMTOXINA | DYSPORT |  |\n| J0587 | INJ, RIMABOTULINUMTOXINB | MYOBLOC |  |\n| J0588 | INCOBOTULINUMTOXIN A | XEOMIN |  |\n| J0589 | INJ DAXIBOTULINUMTOXINA-LANM | DAXXIFY |  |\n| J0593 | INJ., LANADELUMAB-FLYO, 1 MG | TAKHZYRO |  |\n| J0596 | INJECTION, RUCONEST | RUCONEST |  |\n| J0597 | C-1 ESTERASE, BERINERT | BERINERT |  |\n| J0598 | C-1 ESTERASE, CINRYZE | CINRYZE |  |\n| J0638 | CANAKINUMAB INJECTION | ILARIS |  |\n| J0717 | CERTOLIZUMAB PEGOL INJ 1MG | CIMZIA |  |\n| J0725 | CHORIONIC GONADOTROPIN/1000U | PREGNYL/NOVAREL |  |\n| J0775 | COLLAGENASE, CLOST HIST INJ | XIAFLEX |  |\n| J0791 | INJ CRIZANLIZUMAB-TMCA 5MG | ADAKVEO |  |\n| J0870 | INJECTION, IMETELSTAT, 1 MG | RYTELO |  |\n| J0896 | INJ LUSPATERCEPT-AAMT 0 .25MG | REBLOZYL |  |\n| J0897 | DENOSUMAB INJECTION | PROLIA |  |\n\n\n| J1096 | DEXAMETHA OPTH INSERT 0.1 MG | DEXTENZA |\n| --- | --- | --- |\n| J1203 | INJ, CIPAGLUCOSIDASE, 5 MG | POMBILITI |\n| J1290 | ECALLANTIDE INJECTION | KALBITOR |\n| J1299 | INJ, ECULIZUMAB, 2 MG | SOLIRIS |\n| J1300 | Inj, eculizumab, 10mg | SOLIRIS |\n| J1301 | INJECTION, EDARAVONE, 1 MG | RADICAVA |\n| J1302 | INJ, SUTIMLIMAB-JOME, 10 MG | ENJAYMO |\n| J1303 | INJ., RAVULIZUMAB-CWVZ 10 MG | ULTOMIRIS |\n| J1305 | INJ, EVINACUMAB-DGNB, 5MG | EVKEEZA |\n| J1306 | INJECTION, INCLISIRAN, 1 MG | LEQVIO |\n| J1322 | ELOSULFASE ALFA, INJECTION | VIMIZIM |\n| J1323 | INJ, ELRANATAMAB-BCMM, 1 MG | ELREXFIO |\n| J1325 | EPOPROSTENOL INJECTION | Generic VELETRI |\n| J1326 | INJ, ZOLBETUXIMAB-CLZB, 2 MG | VYLOY |\n| J1434 | INJ, FOCINVEZ, 1MG | FOCINVEZ |\n| J1440 | FECAL MICROBIOTA JSLM 1 ML | REBYOTA |\n| J1442 | INJ FILGRASTIM EXCL BIOSIMIL | NEUPOGEN GRANIX OR NIVESTYM |\n| J1458 | GALSULFASE INJECTION | NAGLAZYME |\n| J1459 | INJ IVIG PRIVIGEN 500 MG | PRIVIGEN |\n| J1460 | GAMMA GLOBULIN 1 CC INJ | GAMASTAN |\n| J1551 | INJ CUTAQUIG 100 MG | CUTAQUIG |\n| J1552 | INJ, ALYGLO, 500 MG | ALYGLO |\n| J1554 | INJ. ASCENIV | ASCENIV |\n| J1555 | INJ CUVITRU, 100 MG | CUVIT","cbCaigHqnTX7i8Kf","https://ap.wps.com/l/cbCaigHqnTX7i8Kf","pdf",170515,6,"English","# Effective Prior Authorization Requirements\n## Submission Instructions\n## Coverage and Payment Disclaimer\n# HCPCS Code Drug List","[{\"question\":\"When do these USFHP prior authorization requirements take effect?\",\"answer\":\"They take effect on 04/15/2026.\"},{\"question\":\"How must a prior authorization request be submitted?\",\"answer\":\"Complete the USFHP Prior Authorization Form and fax it with all required clinical documentation to (800) 277-4926.\"},{\"question\":\"Does prior authorization guarantee coverage, eligibility, or payment?\",\"answer\":\"No. Prior authorization does not guarantee coverage, eligibility, or payment on non-covered benefits.\"}]","Medical Injectables Prior Authorization List - USFHP_2026_PC2575 - Effective Date 04/15/2026 | PDF",1789633640]