The following table contains diagnosis-restricted physician-administered drugs and the corresponding diagnosis code and disease descriptions. When a physician-administered drug claim is submitted with a diagnosis listed in this attachment, prior authorization (PA) is not required. For uses outside the listed diagnosis, PA is required. Submission of peer-reviewed medical literature from scientific medical or pharmaceutical publications in which original manuscripts are rejected or published only after having been reviewed by unbiased independent experts to support the proven efficacy of the requested use of the drug is also required to be submitted with the PA request.
Note: This table includes Wisconsin Medicaid’s most current information and may be updated periodically.
Effective: December 1, 2005
| HCPCSCode* | Drug Name | Diagnosis Code | Disease Description |
| J0205 | Alglucerase (Ceredase) | 2727 | Gaucher's Disease |
| J0585 | Botulinum Toxin Type A (Botox) | 3336 | Idiopathic dystonia |
| 3337 | Symptomatic torsion dystonia | ||
| 33381 | Blepharospasm | ||
| 33383 | Spasmodic torticollis | ||
| 33384 | Focal hand dystonia | ||
| 34211 | Spastic hemiplegia and hemiparesis affecting dominant side | ||
| 34212 | Spastic hemiplegia and hemiparesis affecting nondominant side | ||
| 3440-34404, 34409 | Quadriplegia | ||
| 3441 | Paraplegia | ||
| 340 | Multiple Sclerosis | ||
| 3430-3439 | Cerebral palsy | ||
| 3518 | Facial spasm | ||
| 3780-37887 | Strabismus | ||
| 70521 | Hyperhidrosis | ||
| 72885 | Spasm of muscle | ||
| 7810 | Hemifacial spasm | ||
| J0587 | Botulinum Toxin Type B (Myobloc) | 33383 | Spasmodic torticollis |
| J0880, Q0137, and Q4054 | Darbepoetin alfa in albumin solution (Aranesp) | 042, 07953 | Anemia from Acquired Immune Deficiency Syndrome (AIDS) |
| 140-20491, 230-2386, 2388-2399, 2733 | Non-myeloid malignancies or multiple myeloma | ||
| 20610 | Chronic myelomonocytic leukemia | ||
| 2387, 2849, 2850 | Myelodysplastic syndrome | ||
| 28521 | Anemia in chronic kidney disease | ||
| 28522 | Anemia in neoplastic disease | ||
| 585 | Chronic renal failure | ||
| 5851 | Chronic kidney disease, stage I | ||
| 5852 | Chronic kidney disease, stage II (mild) | ||
| 5853 | Chronic kidney disease, stage III (moderate) | ||
| 5854 | Chronic kidney disease, stage IV (severe) | ||
| 5855 | Chronic kidney disease, stage V | ||
| 5856 | End stage renal disease | ||
| 5859 | Chronic kidney disease, unspecified | ||
| J1440 | Filgrastim (Neupogen), 300 mcg | 2880 | Agranulocytosis/Neutropenia |
| J1441 | Filgrastim (Neupogen), 480 mcg | 2880 | Agranulocytosis/Neutropenia |
| J1595 | Glatiramer acetate (Copaxone) | 340 | Multiple Sclerosis |
| J1785 | Imiglucerase (Cerezyme) | 2727 | Gaucher's Disease |
| J1825 | Interferon Beta 1A (Avonex) | 340 | Multiple Sclerosis |
| J1830 | Interferon Beta 1B (Betaseron) | 340 | Multiple Sclerosis |
| J2505 | Pegfilgrastim (Neulasta) | 2880 | Agranulocytosis/Neutropenia |
| J2820 | Sargramostim (Leukine) | 205 | Myeloid leukemia |
| J7505 | Muromonab CD 3 (Orthoclone OKT-3) | 9968 | Organ transplant failure or rejection |
| J9212 | Interferon Alfacon 1 (Infergen) | 7054 | Chronic hepatitis C without mention of hepatic coma |
| J9213 | Interferon Alfa 2A (Roferon-A) | 7054 | Chronic hepatitis C without mention of hepatic coma |
| 1729 | Malignant melanoma | ||
| 1760-1769 | Kaposi's sarcoma | ||
| 2024 | Hairy cell leukemia | ||
| 2028 | Non-hodgkin's lymphoma | ||
| 2030 | Multiple myeloma | ||
| 2051 | Chronic myelocytic leukemia | ||
| 2337 | Bladder carcinoma | ||
| 2339 | Renal cell carcinoma | ||
| J9214 | Interferon Alfa 2B (Intron A) | 7054 | Chronic hepatitis C without mention of hepatic coma |
| 7811 | Condyloma acuminatum | ||
| 1729 | Malignant melanoma | ||
| 1760-1769 | Kaposi's sarcoma | ||
| 2024 | Hairy cell leukemia | ||
| 2028 | Non-hodgkin's lymphoma | ||
| 2030 | Multiple myeloma | ||
| 2337 | Bladder carcinoma | ||
| 2339 | Renal cell carcinoma | ||
| J9215 | Interferon Alfa N3 (Alferon N) | 7811 | Condyloma acuminatum |
| J9216 | Interferon Gamma 1B (Actimmune) | 2881 | Chronic granulomatous disease |
| 75652 | Osteopetrosis | ||
| Q0136 and Q4055 | Epoetin (Epogen and Procrit) | 042, 07953 | Anemia from Acquired Immune Deficiency Syndrome (AIDS) |
| 140-20491, 230-2386, 2388-2399, 2733 | Non-myeloid malignancies or multiple myeloma | ||
| 20610 | Chronic myelomonocytic leukemia | ||
| 2387, 2849, 2850 | Myelodysplastic syndrome | ||
| 28521 | Anemia in chronic kidney disease | ||
| 585 | Chronic renal failure | ||
| 5851 | Chronic kidney disease, stage I | ||
| 5852 | Chronic kidney disease, stage II (mild) | ||
| 5853 | Chronic kidney disease, stage III (moderate) | ||
| 5854 | Chronic kidney disease, stage IV (severe) | ||
| 5855 | Chronic kidney disease, stage V | ||
| 5856 | End stage renal disease | ||
| 5859 | Chronic kidney disease, unspecified | ||
| Q3025 | Interferon Beta 1A (Avonex), IM - 11 mcg | 340 | Multiple Sclerosis |
| Q3026 | Interferon Beta 1A in Albumin (Rebif) | 340 | Multiple Sclerosis |
*HCPCS = Healthcare Common Procedure Coding System
Diagnosis Code-Restricted Drug Home