Medical Injectables Prior Authorization List - USFHP_2026_PC2575 - Effective Date 04/15/2026

Sep 17, 2026

Upload by Blitz

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.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

Effective Prior Authorization Requirements

Submission Instructions

Coverage and Payment Disclaimer

HCPCS Code Drug List

| 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 | | --- | | 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 | | PRIOR AUTHORIZATION DOES NOT GUARANTEE COVERAGE OR ELIGIBILITY
PRIOR AUTHORIZATION DOES NOT GUARANTEE PAYMENT ON NON-COVERED BENEFIT | | HCPCS CODE | CODE DESCRIPTION | DRUG NAME | PREFERRED BIOSIMILAR (IF APPLICABLE) | | --- | --- | --- | --- | | J0129 | ABATACEPT INJECTION | ORENCIA | | | J0172 | INJ, ADUCANUMAB-AVWA, 2 MG | ADUHELM (DISCTON | INUED) | | J0174 | INJ, LECANEMAB-IRMB, 1 MG | LEQEMBI | | | J0175 | INJ, DONANEMAB-AZBT, 2 MG | KISUNLA | | | J0177 | INJ, AFLIBERCEPT HD, 1 MG | EYLEA HD | | | J0180 | AGALSIDASE BETA INJECTION | FABRAZYME | | | J0202 | INJECTION, ALEMTUZUMAB | LEMTRADA | | | J0217 | INJ VELMANASEALFA-TYCV 1 MG | LAMZEDE | | | J0218 | INJ OLIPUDASEALFA-RPCP 1MG | XENPOZYME | | | J0219 | INJAVAL ALFA-NQPT 4MG | NEXVIAZYME | | | J0221 | LUMIZYME INJECTION | LUMIZYME | | | J0222 | INJ., PATISIRAN, 0.1 MG | ONPATTRO | | | J0223 | INJ GIVOSIRAN 0.5 MG | GIVLAARI | | | J0224 | INJ. LUMASIRAN, 0.5 MG | OXLUMO | | | J0225 | INJ, VUTRISIRAN, 1 MG | AMVUTTRA | | | J0256 | ALPHA 1 PROTEINASE INHIBITOR | PROLASTIN C | | | J0257 | GLASSIA INJECTION | GLASSIA | | | J0401 | INJ, ABILIFY MAINTENA, 1 MG | ABILIFY MAINTENA | | | J0402 | INJ, ABILIFY ASIMTUFII, 1 MG | ABILIFY ASIMTUFII | | | J0480 | BASILIXIMAB | SIMULECT | | | J0485 | BELATACEPT INJECTION | NULOJIX | | | J0490 | BELIMUMAB INJECTION | BENLYSTA | | | J0491 | INJANIFROLUMAB-FNIA 1MG | SAPHNELO | | | J0517 | INJ., BENRALIZUMAB, 1 MG | FASENRA | | | J0565 | INJ, BEZLOTOXUMAB, 10 MG | ZINPLAVA | | | J0584 | INJECTION, BUROSUMAB-TWZA 1M | CRYSVITA | | | J0585 | BOTULINUM TOXIN TYPE A PER UNIT | BOTOX | | | J0586 | ABOBOTULINUMTOXINA | DYSPORT | | | J0587 | INJ, RIMABOTULINUMTOXINB | MYOBLOC | | | J0588 | INCOBOTULINUMTOXIN A | XEOMIN | | | J0589 | INJ DAXIBOTULINUMTOXINA-LANM | DAXXIFY | | | J0593 | INJ., LANADELUMAB-FLYO, 1 MG | TAKHZYRO | | | J0596 | INJECTION, RUCONEST | RUCONEST | | | J0597 | C-1 ESTERASE, BERINERT | BERINERT | | | J0598 | C-1 ESTERASE, CINRYZE | CINRYZE | | | J0638 | CANAKINUMAB INJECTION | ILARIS | | | J0717 | CERTOLIZUMAB PEGOL INJ 1MG | CIMZIA | | | J0725 | CHORIONIC GONADOTROPIN/1000U | PREGNYL/NOVAREL | | | J0775 | COLLAGENASE, CLOST HIST INJ | XIAFLEX | | | J0791 | INJ CRIZANLIZUMAB-TMCA 5MG | ADAKVEO | | | J0870 | INJECTION, IMETELSTAT, 1 MG | RYTELO | | | J0896 | INJ LUSPATERCEPT-AAMT 0 .25MG | REBLOZYL | | | J0897 | DENOSUMAB INJECTION | PROLIA | | | J1096 | DEXAMETHA OPTH INSERT 0.1 MG | DEXTENZA | | --- | --- | --- | | J1203 | INJ, CIPAGLUCOSIDASE, 5 MG | POMBILITI | | J1290 | ECALLANTIDE INJECTION | KALBITOR | | J1299 | INJ, ECULIZUMAB, 2 MG | SOLIRIS | | J1300 | Inj, eculizumab, 10mg | SOLIRIS | | J1301 | INJECTION, EDARAVONE, 1 MG | RADICAVA | | J1302 | INJ, SUTIMLIMAB-JOME, 10 MG | ENJAYMO | | J1303 | INJ., RAVULIZUMAB-CWVZ 10 MG | ULTOMIRIS | | J1305 | INJ, EVINACUMAB-DGNB, 5MG | EVKEEZA | | J1306 | INJECTION, INCLISIRAN, 1 MG | LEQVIO | | J1322 | ELOSULFASE ALFA, INJECTION | VIMIZIM | | J1323 | INJ, ELRANATAMAB-BCMM, 1 MG | ELREXFIO | | J1325 | EPOPROSTENOL INJECTION | Generic VELETRI | | J1326 | INJ, ZOLBETUXIMAB-CLZB, 2 MG | VYLOY | | J1434 | INJ, FOCINVEZ, 1MG | FOCINVEZ | | J1440 | FECAL MICROBIOTA JSLM 1 ML | REBYOTA | | J1442 | INJ FILGRASTIM EXCL BIOSIMIL | NEUPOGEN GRANIX OR NIVESTYM | | J1458 | GALSULFASE INJECTION | NAGLAZYME | | J1459 | INJ IVIG PRIVIGEN 500 MG | PRIVIGEN | | J1460 | GAMMA GLOBULIN 1 CC INJ | GAMASTAN | | J1551 | INJ CUTAQUIG 100 MG | CUTAQUIG | | J1552 | INJ, ALYGLO, 500 MG | ALYGLO | | J1554 | INJ. ASCENIV | ASCENIV | | J1555 | INJ CUVITRU, 100 MG | CUVIT

FAQs

When do these USFHP prior authorization requirements take effect?

They take effect on 04/15/2026.

How must a prior authorization request be submitted?

Complete the USFHP Prior Authorization Form and fax it with all required clinical documentation to (800) 277-4926.

Does prior authorization guarantee coverage, eligibility, or payment?

No. Prior authorization does not guarantee coverage, eligibility, or payment on non-covered benefits.

Sep 17, 2026

Upload by Blitz