January 01, 2022

Indiana: New outpatient injectable drug requirements

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:

  • Online: Use the Prior Authorization and Notification tool on UHCprovider.com
  • Call: Use the Provider Services phone number on the member’s health care identification card

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)

Questions?

PCA-1-21-03615-PH-News