PA Lookup

If you have questions about prior authorizations, please call:

Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

CuraMatrix, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4440 (HCPCS) CuraMatrix, per sq cm (add-on, list separately in addition to primary procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Hospice or home health care provided in assisted living facility

Service Code
Q5002 (HCPCS) Hospice or home health care provided in assisted living facility
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Hospice home care provided in a hospice facility

Service Code
Q5010 (HCPCS) Hospice home care provided in a hospice facility
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Injection, ustekinumab-srlf (Imuldosa), biosimilar, 1 mg

Service Code
Q5098 (HCPCS) Injection, ustekinumab-srlf (Imuldosa), biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, ustekinumab-stba (Steqeyma), biosimilar, 1 mg

Service Code
Q5099 (HCPCS) Injection, ustekinumab-stba (Steqeyma), biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, ustekinumab-kfce (Yesintek), biosimilar, 1 mg

Service Code
Q5100 (HCPCS) Injection, ustekinumab-kfce (Yesintek), biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg

Service Code
Q5112 (HCPCS) Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg

Service Code
Q5113 (HCPCS) Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg

Service Code
Q5114 (HCPCS) Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg

Service Code
Q5115 (HCPCS) Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg

Service Code
Q5116 (HCPCS) Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, trastuzumab-anns, biosimilar, (Kanjinti), 10 mg

Service Code
Q5117 (HCPCS) Injection, trastuzumab-anns, biosimilar, (Kanjinti), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg

Service Code
Q5118 (HCPCS) Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, pegfilgrastim-apgf, biosimilar, (Nyvepria), 0.5 mg

Service Code
Q5122 (HCPCS) Injection, pegfilgrastim-apgf, biosimilar, (Nyvepria), 0.5 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mg

Service Code
Q5126 (HCPCS) Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, tocilizumab-aazg (Tyenne), biosimilar, 1 mg

Service Code
Q5135 (HCPCS) Injection, tocilizumab-aazg (Tyenne), biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, denosumab-bbdz (Jubbonti/Wyost), biosimilar, 1 mg

Service Code
Q5136 (HCPCS) Injection, denosumab-bbdz (Jubbonti/Wyost), biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, adalimumab-fkjp, biosimilar, 1 mg

Service Code
Q5140 (HCPCS) Injection, adalimumab-fkjp, biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, adalimumab-aaty, biosimilar, 1 mg

Service Code
Q5141 (HCPCS) Injection, adalimumab-aaty, biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Injection, adalimumab-ryvk biosimilar, 1 mg

Service Code
Q5142 (HCPCS) Injection, adalimumab-ryvk biosimilar, 1 mg
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required