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Effective September, 2022, Mercy Care will be making the following formulary changes and will change the below HCPCS to require Prior Authorization. Per AHCCCS the non-formulary injections will not be covered and will require use of the biosimilar agent*:
Non-Formulary Medication Formulary Alternative
Herceptin - J9355 (non-formulary)
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KANJINTI - Q5117
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OGIVRI - Q5114
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HERZUMA - Q5113
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TRAZIMERA - Q5116
Avastin - J9035 (non-formulary*)
- MVASI - Q5107
- ZIRABEV - Q5118
Rituxan - J9312 (non-formulary)
- TRUXIMA - Q5115
- RIABNI - Q5123
- RUXIENCE - Q5119
*FDA does not recommend use of the biosimilars in the eye. Mercy Care will continue to cover Avastin for use to treat macular degeneration.
Please don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this Notice and all other provider notices on our Mercy Care website.
Thanks for all you do!
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