Provider for MMA -
Services Requiring Prior Authorization

Effective May 5, 2020, per AHCA Policy Transmittal 2020-31 related to COVID-19, all Prior Authorization requirements and service limits for all Behavioral Health Services, including Targeted Case Management, are waived until further notice.

Below is Community Care Plan's list of MMA services that require prior authorization as of December 1st, 2018. Please be advised that effective September 1, 2020, a list of Healthcare Common Procedure Coding System (HCPCS) codes for medications requiring prior authorization has been added.

Please be advised that CCP no longer accepts authorization requests via fax. Providers will need to submit authorization requests via PlanLink, our provider portal, and should include all necessary clinical information.

Please note that all services rendered by out of network providers require prior authorization from Community Care Plan. 

For cases where a participating provider in not available in our network or a non-participating provider is submitting the request, please use our Pre-Certification/Authorization Request Form, click here

 

FOR BEHAVIORAL HEALTH AND SUBSTANCE USE SERVICES
THAT REQUIRE PRIOR AUTHORIZATION, PLEASE CLICK HERE FOR CCP’S BEHAVIORAL HEALTH AUTHORIZATION GUIDELINES.

 

MMA Pharmacy Prior Authorization List

PHYSICIAN INJECTED MEDICATIONS

Code

Procedure code

Brand name

J0129

ABATACEPT 10MG

ORENCIA

J0476

BACLOFEN 50MCG FOR INTRATHECAL TRIAL

LIORESAL, GABLOFEN

J0475

BACLOFEN PER 10MG

LIORESAL, GABLOFEN

J0490

BELIMUMAB 10MG

BENLYSTA

J0585

ONABOTULINUMTOXINA A 1 UNIT

BOTOX

J0717

CERTOLIZUMAB PEGOL 1MG

CIMZIA

J0881

DARBEPOETIN ALFA 1MCG,FOR NON-ESRD USE

ARANESP

J0882

DARBEPOETIN ALFA 1MCG

ARANESP

J0885

EPOETIN ALFA 1,000 UNITS,FOR NON-ESRD USE

PROCRIT

J0897

DENOSUMAB 1MG

PROLIA, XGEVA

J1602

GOLIMUMAB FOR IV USE 1MG

SIMPONI

J1650

ENOXAPARIN SODIUM 10MG

LOVENOX

J1652

FONDAPARINUX SODIUM 0.5MG

ARIXTRA

J1745

INFLIXIMAB 10MG

REMICADE

J1950

LEUPROLIDEACETATE PER 3.75MG (FOR DEPOT SUSPENSION)

LUPRON

J2357

OMALIZUMAB 5MG

XOLAIR

Q5105

EPOETIN ALFA, BIOSIMILAR 100 UNITS 

RETACRIT

Q5106

EPOETIN ALFA, BIOSIMILAR 100 UNITS

RETACRIT

Q5101

FILGRASTIM-SNDZ; BIOSIMILAR 1MCG

ZARXIO

Q5103

INFLIXIMAB-DYYB 10MG

INFLECTRA

Q5104

INFLIXIMAB-ABDA 10MG

RENFLEXIS

Q5108

 PEGFILGRASTIM-JMDB BIOSIMILAR 0.5MG

 FULPHILA

Q5110

FILGRASTIM-AAFI BIOSIMILAR 1MCG

NIVESTYM

Q5111

PEGFILGRASTIM-CBQV BIOSIMILAR 0.5MG

UDENYCA

J7324

HYALURONAN OR DERIVATIVE

ORTHOVISC

J3489

ZOLEDRONIC ACID 1MG

RECLAST OR ZOMETA

J0135

INJECTION, ADALIMUMAB, 20 MG

HUMIRA

J0586

ABOBOTULINUMTOXIN A

DYSPORT

J0587

INJECTION, RIMABOTULINUMTOXIN B

MYOBLOC

J0588

INCOBOTULINUMTOXIN A

XEOMIN