Medical Specialty Drug List for the OhioHealthy Medical Plan - Effective April 1, 2024 - Prior Authorization Submission Instructions

Sep 17, 2026

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Medical Specialty Drug List for the OhioHealthy Medical Plan effective April 1, 2024, outlining prior authorization requirements for specialty drugs routed through the medical benefit. Clinical review is required when specialty drugs are included on the attached list, with submissions routed to Archimedes. Guidance explains how to submit PA when a medication is listed without the requested HCPCS code, and notes exclusions for inpatient or ED billing. It also clarifies that the list is not a formulary and provides search tips by generic name, brand, or HCPCS code, plus updated status and contact submission details.

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CategoryForms

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Pages19

Reading Time7 min

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Authorizations

Medical Benefit Prior Authorizations

Pharmacy Benefit Prior Authorizations

Drug List Organization and Submission Guidance

Medical Specialty Drug List for the OhioHealthy Medical Plan effective April 1, 2024 Authorizations Specialty Drugs that process through the medical benefit will require clinical review if included on the attached list. All specialty drug prior authorizations that process through the medical benefit are routed to Archimedes. If a medication name is listed but not the HCPCS code being requested, please submit PA to ensure coverage. Consult CMS resources for the most recent updates to HCPCS codes. This is not a formulary, nor intended for indication of coverage. Medications billed as Inpatient or ED are not subject to authorization review and do not need to be submitted. Medical Benefit Prior Authorizations For medical benefit specialty medication prior authorizations, please use the forms posted on the OhioHealthy website OR click associated link Archimedes Specialty Drug Authorization Form and fax to 866-491-6971. Pharmacy Benefit Prior Authorizations This list only applies to the medications requiring PA through the Medical Benefit. For specialty drugs through the pharmacy benefit, submit the claim to an in-network pharmacy for processing. Search Tip: This document is organized in alphabetical order by generic name. You can search quickly by brand, generic, or HCPCS Code by using the CTRL + F search function from your keyboard. If you do not know the correct spelling, you can start your search by entering the first few letters of the drug name. This document is only official and current on the OhioHealthyPlans.com website. Drug list is subject to change. Use of older forms may be rejected and delay processing and care to members. © 2022 OhioHealthy Inc. All rights reserved. Last Updated 4/1/2024 | HCPCS Code | Generic Drug Name | Brand Drug Name | Prior Authorization Submission | | --- | --- | --- | --- | J8597 Unclassified Antiemetic Drug (other) Unclassified Antiemetic Drug (other) Submit PA to Archimedes | J8498 | Unclassified Antiemetic Drug
(suppository) | Unclassified Antiemetic
Drug (suppository) | Submit PA to Archimedes | | --- | --- | --- | --- | | J9999 | Unclassified Antineoplastic Drug | Unclassified
Antineoplastic Drug | Submit PA to Archimedes | | J3590 | Unclassified Biologic | Unclassified Biologic | Submit PA to Archimedes | | J3490 | Unclassified Drug | Unclassified Drug | Submit PA to Archimedes | | C9399 | Unclassified Drug Or Biological | Unclassified Drug Or Biological | Submit PA to Archimedes | | J7599 | Unclassified Immunosuppressive Drug | Unclassified Immunosuppressive Drug | Submit PA to Archimedes | | J7699 | Unclassified Inhalation Solution
(DME) | Unclassified Inhalation Solution (DME) | Submit PA to Archimedes | | J8999 | Unclassified Oral Chemo Drug | Unclassified Oral
Chemo Drug | Submit PA to Archimedes | | J8499 | Unclassified Oral Non-Chemo Drug | Unclassified Oral NonChemo Drug | Submit PA to Archimedes | | J7799 | Unclassified Other Drug (DME) | Unclassified Other
Drug (DME) | Submit PA to Archimedes | | J0129 | abatacept IV | Orencia (IV) | Submit PA to Archimedes | | | abatacept SC | Orencia (SC) | Submit to network Pharmacy for Processing | | J0586 | abobotulinumtoxina | Dysport | Submit PA to Archimedes | | TBD | ADAMTS13 Recombinant-krhn | Adzynma | Submit PA to Archimedes | | J9354 | ado-trastuzumab emtansine | Kadcyla | Submit PA to Archimedes | | J0172 | aducanumab | Aduhelm | Submit PA to Archimedes | | J7352 | afamelanotide implant | Scenesse | Submit PA to Archimedes | | TBD | aflibercept | Eylea HD | Submit PA to Archimedes | | J0178 | aflibercept | Eylea | Submit PA to Archimedes | | J0180 | agalsidase beta | Fabrazyme | Submit PA to Archimedes | | J0215 | alefacept | Amevive | Submit PA to Archimedes | | J9010 | alemtuzumab | Campath | Submit PA to Archimedes | | J0202 | alemtuzumab | Lemtrada | Submit PA to Archimedes | | J0205 | alglucerase | Ceredase | Submit PA to Archimedes | | J0221 | alglucosidase alfa | Lumizy

FAQs

Which specialty drugs require clinical review under the OhioHealthy medical benefit?

Specialty drugs that process through the medical benefit and are included on the attached list require clinical review prior to authorization.

Where should prior authorizations for medical benefit specialty medications be routed?

Medical benefit specialty medication prior authorizations must be routed to Archimedes using the forms posted on the OhioHealthy website or the associated Archimedes Specialty Drug Authorization Form faxed to 866-491-6971.

Does this document apply to pharmacy benefit specialty drugs?

No. This list applies only to medications requiring PA through the Medical Benefit; pharmacy benefit specialty drugs should be processed by submitting the claim to an in-network pharmacy.

Sep 17, 2026

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