Medication Codes (Not Requiring PA)

The following is a list of medications that do not require PA in the office or outpatient setting:

J0100 – J0999

J0131 – Acetaminophen injection
J0132 – Acetylcysteine injection
J0133 – Acyclovir injection
J0150 – Injection adenosine 6 mg
J0151 – Inj adenosine diag 1mg
J0152 – Adenosine injection
J0153 – Adenosine inj 1mg
J0171 – Adrenalin epinephrine inject
J0190 – Inj biperiden lactate/5mg
J0200 – Alatrofloxacin mesylate
J0207 – Amifostine
J0210 – Methyldopate hcl injection
J0278 – Amikacin sulfate injection
J0280 – Aminophyllin 250 mg inj
J0282 – Amiodarone hcl
J0285 – Amphotericin b
J0287 – Amphotericin b lipid complex
J0288 – Ampho b cholesteryl sulfate
J0289 – Amphotericin b liposome inj
J0290 – Ampicillin 500 mg inj
J0295 – Ampicillin sodium per 1.5 gm
J0300 – Amobarbital 125 mg inj
J0330 – Succinycholine chloride inj
J0348 – Anidulafungin injection
J0350 – Injection anistreplase 30 u
J0360 – Hydralazine hcl injection
J0364 – Apomorphine hydrochloride
J0365 – Aprotonin, 10,000 kiu
J0380 – Inj metaraminol bitartrate
J0456 – Azithromycin
J0461 – Atropine sulfate injection
J0470 – Dimecaprol injection
J0500 – Dicyclomine injection
J0515 – Inj benztropine mesylate
J0520 – Bethanechol chloride inject
J0558 – Peng benzathine/procaine inj
J0561 – Penicillin g benzathine inj
J0583 – Bivalirudin
J0594 – Busulfan injection
J0595 – Butorphanol tartrate 1 mg
J0610 – Calcium gluconate injection
J0620 – Calcium glycer & lact/10 ml
J0636 – Inj calcitriol per 0.1 mcg
J0637 – Caspofungin acetate
J0640 – Leucovorin calcium injection
J0641 – Levoleucovorin injection
J0670 – Inj mepivacaine hcl/10 ml
J0690 – Cefazolin sodium injection
J0692 – Cefepime hcl for injection
J0694 – Cefoxitin sodium injection
J0695 – Inj ceftolozane tazobactam
J0696 – Ceftriaxone sodium injection
J0697 – Sterile cefuroxime injection
J0698 – Cefotaxime sodium injection
J0706 – Caffeine citrate injection
J0710 – Cephapirin sodium injection
J0712 – Ceftaroline fosamil inj
J0713 – Inj ceftazidime per 500 mg
J0714 – Ceftazidime and avibactam
J0715 – Ceftizoxime sodium / 500 mg
J0716 – Centruroides immune f(ab)
J0720 – Chloramphenicol sodium injec
J0735 – Clonidine hydrochloride
J0743 – Cilastatin sodium injection
J0744 – Ciprofloxacin iv
J0745 – Inj codeine phosphate /30 mg
J0760 – Colchicine injection
J0770 – Colistimethate sodium inj
J0780 – Prochlorperazine injection
J0840 – Crotalidae poly immune fab
J0875 – Injection, dalbavancin
J0878 – Daptomycin injection
J0895 – Deferoxamine mesylate inj

J2000 – J2999

J2001 – Lidocaine injection
J2010 – Lincomycin injection
J2020 – Linezolid injection
J2060 – Lorazepam injection
J2150 – Mannitol injection
J2175 – Meperidine hydrochl /100 mg
J2180 – Meperidine/promethazine inj
J2210 – Methylergonovin maleate inj
J2248 – Micafungin sodium injection
J2250 – Inj midazolam hydrochloride
J2260 – Inj milrinone lactate / 5 mg
J2265 – Minocycline hydrochloride
J2270 – Morphine sulfate injection
J2271 – Morphine so4 injection 100mg
J2274 – In morphine preservativ free
J2275 – Morphine sulfate injection
J2278 – Ziconotide injection
J2280 – Inj, moxifloxacin 100 mg
J2300 – Inj nalbuphine hydrochloride
J2310 – Inj naloxone hydrochloride
J2370 – Phenylephrine hcl injection
J2400 – Chloroprocaine hcl injection
J2405 – Ondansetron hcl injection
J2410 – Oxymorphone hcl injection
J2425 – Palifermin injection
J2430 – Pamidronate disodium/30mg
J2469 – Palonosetron hcl
J2510 – Penicillin g procaine inj
J2513 – Pentastarch 10% solution
J2515 – Pentobarbital sodium inj
J2540 – Penicillin g potassium inj
J2543 – Piperacillin/tazobactam
J2550 – Promethazine hcl injection
J2560 – Phenobarbital sodium inj
J2590 – Oxytocin injection
J2690 – Procainamide hcl injection
J2700 – Oxacillin sodium injeciton
J2704 – Inj, propofol, 10 mg
J2710 – Neostigmine methylslfte inj
J2720 – Inj protamine sulfate/10 mg
J2730 – Pralidoxime chloride inj
J2760 – Phentolaine mesylate inj
J2765 – Metoclopramide hcl injection
J2770 – Quinupristin/dalfopristin
J2780 – Ranitidine hydrochloride inj
J2783 – Rasburicase
J2795 – Ropivacaine hcl injection
J2810 – Inj theophylline per 40 mg
J2950 – Promazine hcl injection
J2993 – Reteplase injection
J2995 – Inj streptokinase /250000 iu
J2997 – Alteplase recombinant

J7000 – J7999

J7030 – Normal saline solution infus
J7040 – Normal saline solution infus
J7042 – 5% dextrose/normal saline
J7050 – Normal saline solution infus
J7060 – 5% dextrose/water
J7070 – D5w infusion
J7100 – Dextran 40 infusion
J7110 – Dextran 75 infusion
J7120 – Ringers lactate infusion
J7121 – 5% dextrose in lac ringers
J7131 – Hypertonic saline sol
J7297 – Liletta, 52 mg
J7298 – Mirena, 52 mg
J7300 – Intraut copper contraceptive
J7301 – Skyla, 13.5 mg
J7302 – Levonorgestrel iu 52 mg
J7303 – Contraceptive vaginal ring
J7304 – Contraceptive hormone patch
J7306 – Levonorgestrel implant sys
J7307 – Etonogestrel implant system
J7340 – Carbidopa levodopa ent 100ml
J7604 – Acetylcysteine comp unit
J7608 – Acetylcysteine non-comp unit
J7611 – Albuterol non-comp con
J7612 – Levalbuterol non-comp unit
J7613 – Albuterol non-comp unit
J7614 – Levalbuterol non-comp unit
J7620 – Albuterol iprotrop non-com
J7626 – Budesonide non-comp unit
J7631 – Cromolyn sodium non0comp unit
J7644 – Ipratropium bromide non-comp
J7648 – Isoetharine non-comp con
J7649 – Isoetharine non-comp unit
J7668 – Metaproterenol non-comp con
J7669 – Metaproterenol non-comp unit
J7674 – Methacholine chloride, neb
J7682 – Tobramycin non-comp unit

J1000 – J1999

J1020 Methylprednisolone 20mg Inj
J1030 Methylprednisolone 40mg Inj
J1040 Methylprednisolone 80mg Inj
J1100 – Dexamethasone Injection
J1110 – Inj dihydroergotamine mesylt
J1120 – Acetazolamid sodium injection
J1130 – Inj diclofenac sodium 0.5mg
J1160 – Digoxin injection
J1162 – Digoxin immune fab (ovine)
J1165 – Phenytoin sodium injection
J1170 – Hydromorphone injection
J1180 – Dyphylline injection
J1190 – Dexrazoxane hcl injection
J1200 – Diphenhydramine hcl injectio
J1205 – Chlorothiazide sodium inj
J1230 – Methadone injection
J1240 – Dimenhydrinate injection
J1245 – Dipyridamole injection
J1250 – Inj dobutamine hcl/250 mg
J1260 – Dolasetron mesylate
J1265 – Dopamine injection
J1267 – Doripenem injection
J1320 – Amitriptyline injection
J1327 – Eptifibatide injection
J1330 – Ergonovine maleate injection
J1335 – Ertapenem injection
J1364 – Erythro lactobionate /500 mg
J1440 – Filgrastim 300 mcg injection
J1441 – Filgrastim 480 mcg injection
J1442 – Inj filgrastim excl biosimil
J1453 – Fosaprepitant injection
J1457 – Gallium nitrate injection
J1580 – Garamycin gentamicin inj
J1590 – Gatifloxacin injection
J1610 – Glucagon hydrochloride/1 mg
J1626 – Granisetron hcl injection
J1630 – Haloperidol injection
J1631 – Haloperidol decanoate inj
J1642 – Inj heparin sodium per 10 u
J1644 – Inj heparin sodium per 1000u
J1645 – Dalteparin sodium
J1650 – Inj enoxaparin sodium
J1652 – Fondaparinux sodium
J1655 – Tinzaparin sodium injection
J1670 – Tetanus immune globulin inj
J1700 Hydrocortisone acetate inj
J1710 Hydrocortisone sodium ph inj
J1720 Hydrocortisone sodium succ inj
J1741 – Ibuprofen injection
J1742 – Ibutilide fumarate injection
J1790 – Droperidol injection
J1800 – Propranolol injection
J1810 – Droperidol/fentanyl inj
J1815 – Insulin injection
J1817 – Insulin for insulin pump use
J1835 – Itraconazole injection
J1840 – Kanamycin sulfate 500 mg inj
J1850 – Kanamycin sulfate 75 mg inj
J1885 – Ketorolac tromethamine inj
J1890 – Cephalothin sodium injection
J1940 – Furosemide injection
J1953 – Levetiracetam injection
J1955 – Inj levocarnitine per 1 gm
J1956 – Levofloxacin injection
J1960 – Levorphanol tartrate inj
J1980 – Hyoscyamine sulfate inj
J1990 – Chlordiazepoxide injection
J1950 – Leuprolide injection 3.75 mg

J3000 – J3999

J3000 – Streptomycin injection
J3010 – Fentanyl citrate injeciton
J3070 – Pentazocine injection
J3090 – Inj tedizolid phosphate
J3095 – Telavancin injection
J3101 – Tenecteplase injecton
J3105 – Terbutaline sulfate inj
J3230 – Chlorpromazine hcl injection
J3250 – Trimethobenzamide hcl inj
J3260 – Tobramycin sulfate injection
J3265 – Injection torsemide 10 mg/ml
J3280 – Thiethylperazine maleate inj
J3300 Triamcinolone a inj prs-free
J3301 Triamcinolone act inj nos
J3302 Triamcinolone diacetate inj
J3303 Triamcinolone hexacetonl inj with CPTs 20600 and 20605)
J3305 – Inj trimetrexate glucoronate
J3320 – Spectinomycn di-hcl inj
J3360 – Diazepam injection
J3364 – Urokinase 5000 iu injection
J3365 – Urokinase 250, 000 iu inj
J3370 – Vancomycin hcl injection
J3410 – Hydroxyzine hcl injection
J3411 – Thiamine hcl 100 mg
J3415 – Pyridoxine hcl 100 mg
J3430 – Vitamin k phytonadione inj
J3475 – Inj magnesium sulfate
J3480 – Inj potassium chloride
J3530 – Nasal vaccine inhalation
J3535 – Metered dose inhaler drug

J9000 – J9999

J9017 – Arsenic trioxide injection
J9019 – Erwinaze injection
J9020 – Asparaginase, nos
J9025 – Azacitidine injection
J9027 – Clofarabine injection
J9031 – Bcg live intravesical vac
J9033 – Inj., treanda 1 mg
J9040 – Bleomycin sulfate injection
J9043 – Cabazitaxel injection
J9045 – Carboplatin injection
J9041 – Velcade (bortezomib); Cortisone joint injections with CPTs 20600 or 20605.
J9050 – Carmustine injection
J9060 – Cisplatin 10 mg injection
J9065 – Inj cladribine per 1 mg
J9070 – Cyclophosphamide 100 mg inj
J9100 – Cytarabine hcl 100 mg inj
J9130 – Dacarbazine 100 mg inj
J9150 – Daunorubicin injection
J9151 – Daunorubicin citrate inj
J9155 – Degarelix injection
J9171 – Docetaxel injection
J9175 – Elliotts b solution per ml
J9178 – Inj, epirubicin hcl, 2 mg
J9181 – Etoposide injection
J9190 – Fluorouracil injection
J9200 – Floxuridine injection
J9201 – Gemcitabine hcl injection
J9208 – Ifosfamide injection
J9209 – Mesna injection
J9211 – Idarubicin hcl injection
J9217 – Leuprolide Injection 7.5 mg
J9230 – Mechlorethamine hcl inj
J9263 – Oxaliplatin
J9264 – Paclitaxel protein bound
J9265 – Paclitaxel injection
J9267 – Paclitaxel injection
J9280 – Mitomycin injection
J9293 – Mitoxantrone hydrochl / 5 mg
J9320 – Streptozocin injection
J9340 – Thiotepa injection
J9351 – Topotecan injection
J9352 – Injection trabectedin 0.1mg
J9360 – Vinblastine sulfate inj
 J9370 – Vincristine sulfate 1 mg inj
J9371 – Inj, vincristine sul lip 1mg
J9390 – Vinorelbine tartrate inj

Medication Assisted Chemical Dependency Treatment requires a Prior Authorization

Download The Prior Authorization Guidelines

For information on prior authorization requirements for medications obtained at pharmacies, please see the PrimaryHealth Medication Formulary on our website or you can call (541) 471-4208.