Effective April 1, 2022, we will require prior authorization for the medications listed in the table below for UnitedHealthcare Community Plan of Indiana members. You can submit prior authorization requests in the following ways:
We may deny your claim if you administer any of these medications without following the prior authorization process. You can’t bill for services denied due to failure to complete the prior authorization.
| HCPCS code | Description |
|---|---|
J1554 |
Asceniv™ (immune globulin intravenous, human) |
J9217 |
Eligard®, Lupron Depot® (leuprolide acetate) |
J9155 |
Firmagon® (degarelix) |
J2507 |
Krystexxa® (pegloticase) |
J3490 |
Lupaneta Pack™ (leuprolide acetate injection and norethindrone acetate tablets) |
J1950 |
Lupron Depot®, Lupron Depot-PED® (leuprolide acetate) |
J2796 |
Nplate® (romiplostim) |
Q5122 |
Nyvepria™ (pegfligrastim-apgf) |
J2354 |
Octreotide Acetate |
Q5123 |
Riabni™ (rituximab-arrx) |
J2353 |
Sandostatin LAR® (octreotide acetate) |
J2502 |
Signifor LAR® (pasireotide) |
J1930 |
Somatuline Depot® (lanreotide) |
J9226 |
Supprelin LA® (histrelin acetate) |
J3315 |
Trelstar® (triptorelin pamoate) |
J3316 |
Triptodur® (triptorelin) |
J1823 |
Uplizna™ (inebilizumab-cdon) |
J9225 |
Vantas™ (histrelin implant) |
J9202 |
Zoladex® (goserelin acetate implant) |
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