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

Injection, adalimumab-adbm, biosimilar, 1 mg

Service Code
Q5143 (HCPCS) Injection, adalimumab-adbm, 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-aacf (Idacio), biosimilar, 1 mg

Service Code
Q5144 (HCPCS) Injection, adalimumab-aacf (Idacio), 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-afzb (Abrilada), biosimilar, 1 mg

Service Code
Q5145 (HCPCS) Injection, adalimumab-afzb (Abrilada), 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-strf (Hercessi), biosimilar, 10 mg

Service Code
Q5146 (HCPCS) Injection, trastuzumab-strf (Hercessi), biosimilar, 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, aflibercept-ayyh (Pavblu), biosimilar, 1 mg

Service Code
Q5147 (HCPCS) Injection, aflibercept-ayyh (Pavblu), 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, filgrastim-txid (Nypozi), biosimilar, 1 mcg

Service Code
Q5148 (HCPCS) Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcg
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, aflibercept-abzv (Enzeevu), biosimilar, 1 mg

Service Code
Q5149 (HCPCS) Injection, aflibercept-abzv (Enzeevu), 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, aflibercept-mrbb (Ahzantive), biosimilar, 1 mg

Service Code
Q5150 (HCPCS) Injection, aflibercept-mrbb (Ahzantive), 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, eculizumab-aagh (Epysqli), biosimilar, 2 mg

Service Code
Q5151 (HCPCS) Injection, eculizumab-aagh (Epysqli), biosimilar, 2 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, eculizumab-aeeb (Bkemv), biosimilar, 2 mg

Service Code
Q5152 (HCPCS) Injection, eculizumab-aeeb (Bkemv), biosimilar, 2 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, aflibercept-yszy (Opuviz), biosimilar, 1 mg

Service Code
Q5153 (HCPCS) Injection, aflibercept-yszy (Opuviz), 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-kyqq (Aukelso/Bosaya), biosimilar, 1 mg

Service Code
Q5161 (HCPCS) Injection, denosumab-kyqq (Aukelso/Bosaya), biosimilar, 1 mg
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

Injection, denosumab-nxxp (Bildyos/Bilprevda), biosimilar, 1 mg

Service Code
Q5162 (HCPCS) Injection, denosumab-nxxp (Bildyos/Bilprevda), biosimilar, 1 mg
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

Q9967 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML

Service Code
Q9967 (HCPCS) Q9967 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML
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-ttwe (Pyzchiva), subcutaneous, 1 mg

Service Code
Q9996 (HCPCS) Injection, ustekinumab-ttwe (Pyzchiva), subcutaneous, 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-ttwe (Pyzchiva), intravenous, 1 mg

Service Code
Q9997 (HCPCS) Injection, ustekinumab-ttwe (Pyzchiva), intravenous, 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-aekn (Selarsdi), 1 mg

Service Code
Q9998 (HCPCS) Injection, ustekinumab-aekn (Selarsdi), 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-aauz (Otulfi), biosimilar, 1 mg

Service Code
Q9999 (HCPCS) Injection, ustekinumab-aauz (Otulfi), biosimilar, 1 mg
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

Injection, menotropins, 75 IU

Service Code
S0122 (HCPCS) Injection, menotropins, 75 IU
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, follitropin alfa, 75 IU

Service Code
S0126 (HCPCS) Injection, follitropin alfa, 75 IU
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