MDwise Managed Medicaid Prior Authorization Guidelines for Medical Benefit Neutral Drugs

• ADO-TRASTUZUMAB EMTANSINE

  Generic	Brand	HICL	GCN	HCPC
  ADO-TRASTUZUMAB EMTANSINE	KADCYLA	40046		J9354

• ADUCANUMAB-AVWA

  Generic	Brand	HICL	GCN	HCPC
  ADUCANUMAB-AVWA	ADUHELM	47421		J0172

• AFAMITRESGENE AUTOLEUCEL

  Generic	Brand	HICL	GCN	HCPC
  AFAMITRESGENE AUTOLEUCEL	TECELRA	49787		Q2057

• AFLIBERCEPT-AYYH

  Generic	Brand	HICL	GCN	HCPC
  AFLIBERCEPT-AYYH	PAVBLU	49830		Q5147

• AFLIBERCEPT-EYLEA

  Generic	Brand	HICL	GCN	HCPC
  AFLIBERCEPT	EYLEA		30919 34816	J0178

• AFLIBERCEPT-EYLEA HD

  Generic	Brand	HICL	GCN	HCPC
  AFLIBERCEPT	EYLEA HD		54599	J0177

• ALGLUCOSIDASE ALFA

  Generic	Brand	HICL	GCN	HCPC
  ALGLUCOSIDASE ALFA	Lumizyme	33588		J0220 J0221

• AMIVANTAMAB-VMJW

  Generic	Brand	HICL	GCN	HCPC
  AMIVANTAMAB-VMJW	RYBREVANT	47385		J9061

• ANIFROLUMAB-FNIA

  Generic	Brand	HICL	GCN	HCPC
  ANIFROLUMAB-FNIA	SAPHNELO	47512		J0491

• ATEZOLIZUMAB

  Generic	Brand	HICL	GCN	HCPC
  ATEZOLIZUMAB	TECENTRIQ	43408		J9022

Approval code: DR-10-2025-18827/HHW-HIPP1047 (10/25)