CurrentBaylor Scott & White Health PlanPolicy N/A

Medications Restricted to Medical Benefit

List of medications and HCPCS codes that must be billed to the member's medical benefit when administered by a health care professional in outpatient/office/infusion settings; affects providers and billing for Baylor Scott and White Health Plan members (document excerpt covers portion of the full list).

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedications Restricted to Medical Benefit

Policy CodePolicy N/A

Change TypeNo material change / informational list

Effective DateN/A

Next Review DateN/A

Key ActionCheck plan/formulary and obtain prior authorization when required before billing medications to the medical benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+distinct HCPCS/J‑codes listed (excerpt)

Most = Yesitems marked HIM formulary

repeatedprior authorization advisory

Yes/Noformulary flags shown

Medications Routed to the Medical Benefit — Coverage Criteria

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inv-01: Billing criteria and notices

Billing requirement and caveats

Medications administered by health care professionals within physician offices, infusion centers, or outpatient settings must be billed to the member's medical benefit when listed as restricted to the medical benefit.

Examples of routes always restricted

Epidural route (expected to be administered by a health care professional and therefore restricted to the medical benefit).
Implant route (expected to be administered by a health care professional and therefore restricted to the medical benefit).
Intraocular route (expected to be administered by a health care professional and therefore restricted to the medical benefit).

Presence on the list does not guarantee coverage; drugs may be subject to coverage requirements or limits such as prior authorization. Refer to your formulary or plan documents for additional information.

inv-02: HCPCS to restriction mapping (partial)

Per-drug coding guidance (examples shown in excerpt)

HCPCS code J0401 (Aripiprazole IM for Extended Release) appears in the listing with GPI mappings and HIM/Formulary flags; check the specific line item for whether the item is restricted to the medical benefit (examples show both Yes and No for different strengths/formulations).

HCPCS code J9264 (Paclitaxel Protein-Bound Particles / Abraxane) is listed with HIM/Formulary flags indicating restriction to the medical benefit (Yes).

inv-03: Sample medication routing rows

Entries indicate medication routing to medical benefit and HIM/Formulary status.

J7345 — Ameluz (Aminolevulinic Acid HCl Gel 10%): listed as Directed to Medical Benefit = Yes; HIM Formulary = Yes; Group Value/Group Choice Formulary = No; GPI shown in line item.

J0282 — Amiodarone HCl inj (various vial sizes): listed as Directed to Medical Benefit = Yes; HIM Formulary = Yes; Group Value/Group Choice Formulary = Yes; GPI entries shown per strength.

J0290 — Ampicillin Sodium (IV solutions): listed as Directed to Medical Benefit = Yes; HIM Formulary = Yes; Group Value/Group Choice Formulary = No; GPI entries shown per strength.

inv-04: Coverage guidance and list usage

Listings direct medications to the medical benefit and include formulary flags; coverage may still require authorization or be limited.

Each drug line includes a HCPCS/CPT or other code, a GPI, drug name, generic description, a Health Insurance Marketplace (HIM) formulary flag, and a Group Value/Group Choice formulary flag (line-level details provided in the list).

Presence on the list does not guarantee coverage; drugs may be subject to coverage requirements or limits such as prior authorization. Providers should consult formulary/plan documents for additional information.

Entries indicate HIM Formulary = Yes or No and Group Value/Group Choice Formulary = Yes or No, varying by line item.

inv-05: Coverage stance and notes

General coverage guidance and disclaimers

Drugs may be subject to coverage requirements or limits such as prior authorization; refer to your formulary or plan documents for additional information.

This list does not guarantee coverage.

Individual line items include HIM and Group Value/Group Choice formulary flags; coverage depends on plan/formulary and may differ between marketplace and group formularies.

inv-06: Medical benefit drug listing and disclaimers

Coverage guidance and limitations noted in this segment

Drugs listed are directed to the medical benefit; each entry includes HCPCS code, drug name, generic description, HIM formulary flag, and Group Value/Group Choice formulary flag.

This list does not guarantee coverage and drugs may be subject to coverage requirements or limits such as prior authorization; check formulary or plan documents for specifics.

Some items show HIM Formulary = Yes while Group Value/Group Choice Formulary = No, indicating differences between marketplace and group formulary coverage for certain line items.

inv-07: List entries and formulary flags

Entries include GPI, drug name, generic description, and HIM formulary flags where present.

Line items for cephalosporins and related agents (e.g., J0694, J0713, J0696) show GPI values, drug names, generic descriptions, and HIM Formulary = Yes; Group Value/Group Choice Formulary varies by strength/line item.

inv-08: Coverage guidance (excerpt)

Coverage notes and limitations

Multiple contrast agents and IV drug entries (e.g., A9575, J0736) are listed with HIM Formulary = Yes and Group Value/Group Choice Formulary indicated per line; drugs may still require prior authorization.

The list reiterates that drugs may be subject to coverage requirements or limits such as prior authorization and that listing does not guarantee coverage.

inv-09: Coverage caveats and item structure

Coverage caveats and item structure

Each line item includes: HCPCS/J-code or other code, GPI, Drug name, Generic description, HIM Formulary flag, and Group Value/Group Choice Formulary flag as shown in the list.

This list does not guarantee coverage; drugs may be subject to coverage requirements or limits such as prior authorization — providers should refer to formulary/plan documents for additional details.

inv-10: General coverage notes

General coverage note included in the listing

Line items (e.g., Definity, Defitelio) are marked with HIM Formulary flags and Group Value/Group Choice flags; coverage may differ by product/packaging and may require prior authorization.

The list repeatedly warns that drugs may be subject to coverage requirements or limits and that inclusion on the list does not guarantee coverage.

inv-11: Coverage caveats and list structure

General coverage caveats applying to entries in this list

Drugs listed may be subject to coverage requirements or limits such as prior authorization; consult formulary or plan documents for specifics.

Each entry includes code (e.g., J-code), GPI, drug name, generic description, HIM Formulary flag, and Group Value/Group Choice formulary flag.

This list does not guarantee coverage.

inv-12: Medications directed to medical benefit — entries and formulary flags

Entries include HCPCS/J-code, GPI, drug name, generic description, HIM formulary status, and Group Value/Choice formulary status.

High-cost/gene therapy kit entries (e.g., J1413 Elevidys weight‑based kits) are listed with GPI values and show HIM Formulary = No and Group Value/Group Choice Formulary = Yes for the kit entries shown.

inv-13: Medical-benefit directed medications (partial list)

List of medications routed to the medical benefit with formulary indicators; coverage may require additional plan-level requirements.

Examples in this partial list include Entyvio (J3380) and Epoprostenol (J1325) with HIM Formulary and Group Value flags indicated per line item; most entries direct billing to the medical benefit.

The list reiterates that drugs may be subject to coverage requirements or limits such as prior authorization and that inclusion on the list does not guarantee coverage.

inv-14: Formulary designation and coverage notice

List entries include formulary flags indicating whether the drug is on the Health Insurance Marketplace (HIM) formulary and Group Value/Group Choice formulary. Specific coverage decisions may require review of plan documents or prior authorization.

Multiple immunoglobulins, oncologic agents, and diagnostic agents are included (examples: J9155, 90283, J9185, A9552, A9585) with HIM Formulary flags and Group Value/Group Choice flags shown per line item.

Providers should note that HIM Formulary = Yes does not necessarily equate to group formulary coverage; Group Value/Group Choice flags vary by product and packaging.

inv-15: Coverage stance for listed medications

The document lists medications directed to the medical benefit along with formulary indicators; coverage may require prior authorization and is subject to plan/formulary rules.

Examples (e.g., Gentamicin in Saline J1580, Granisetron J1626, Haldol Decanoate J1631) are shown with HIM Formulary = Yes and Group Value/Group Choice values indicated per line; consult plan documents for coverage specifics.

The list reiterates that drugs may be subject to coverage requirements or limits such as prior authorization and that inclusion on the list does not guarantee coverage.

inv-16: Coverage criteria and caveats

Coverage stance and caveats for the listed medical-benefit drugs in this segment.

Listed drugs in this segment (examples include Hemgenix J1411, Heparin J1644, HepaGam J1571, Hyqvia J1575) are directed to the medical benefit and include HIM and Group Value/Group Choice formulary indicators.

Drugs may be subject to coverage requirements or limits such as prior authorization; consult formulary or plan documents for specifics regarding coverage and prior authorization requirements.

This list does not guarantee coverage.

Examples: Hemgenix (J1411) is listed across multiple GPI pack sizes and marked HIM Formulary = Yes and Group Value/Group Choice Formulary = Yes in the shown lines.

HCPCS / J‑code / GPI Mappings and Code Examples

HCPCS / J-codes directed to medical benefitHCPCS

J2997

Infliximab biosimilar (sample mapping)

What Providers Must Do / Watch For

Prior Authorization

Prior authorization notice

Drugs on this medical‑benefit list may be subject to coverage requirements or limits such as prior authorization; consult the member's formulary or plan documents for details.

Prior Authorization

Prior authorization and coverage limits notice

Drugs on this list may be subject to coverage requirements or limits such as prior authorization and this list does not guarantee coverage; providers should refer to applicable formulary or plan documents for additional information.

Prior Authorization

Prior authorization advisory

Drugs may be subject to coverage requirements or limits such as prior authorization; refer to your formulary or plan documents for additional information.

Prior Authorization

Prior authorization / coverage limits notice

Drugs on this list may be subject to coverage requirements or limits such as prior authorization; consult the member's formulary or plan documents for additional details.

Prior Authorization

Prior authorization advisory

Drugs may be subject to coverage requirements or limits such as prior authorization; providers should check formulary or plan documents for specifics.

Prior Authorization

Prior authorization advisory

Drugs may be subject to coverage requirements or limits such as prior authorization; refer to your formulary or plan documents for additional information.

Prior Authorization

Prior authorization notice

Drugs listed are subject to coverage requirements or limits such as prior authorization; consult formulary or plan documents for additional information.

Prior Authorization

Prior authorization notice

Drugs may be subject to coverage requirements or limits such as prior authorization; refer to the member's formulary or plan documents for more information.

Prior Authorization

Prior authorization advisory

Drugs may be subject to coverage requirements or limits such as prior authorization; check plan/formulary documents for coverage details.

Prior Authorization

Prior authorization / coverage limits notice

Drugs listed may be subject to coverage requirements or limits such as prior authorization; consult the member's formulary or plan documents for specifics.

Prior Authorization

Prior authorization / coverage limits notice

Drugs on this list may be subject to coverage requirements or limits such as prior authorization; this list does not guarantee coverage — consult formulary or plan documents.

Prior Authorization

Prior authorization and coverage disclaimer

Drugs may be subject to coverage requirements or limits such as prior authorization and this list does not guarantee coverage; refer to the member's formulary or plan documents for details.

Prior Authorization

Prior authorization notice

Drugs may be subject to coverage requirements or limits such as prior authorization; consult formulary or plan documents for coverage specifics.

Prior Authorization

Prior authorization advisory

Drugs may be subject to coverage requirements or limits such as prior authorization; refer to your formulary or plan documents for additional information.

Prior Authorization

Prior authorization advisory (repeated)

Drugs may be subject to coverage requirements or limits such as prior authorization; consult the formulary or plan documents for details.

Prior Authorization

Prior authorization advisory

Drugs may be subject to coverage requirements or limits such as prior authorization; refer to your formulary or plan documents for additional information.

Denial Risk

Coverage disclaimer

This list does not guarantee coverage.

Key Terms and Table Field Mapping

Medications Restricted to Medical Benefit

DefinitionMedications restricted to the medical benefit: drugs that must be billed under the member's medical benefit when administered by a health care professional in outpatient/office/infusion settings

Routes always restricted (examples)Epidural, implant, and intraocular administrations are examples of routes expected to be restricted to the medical benefit

Billing note*Yes = Medication is restricted to the medical benefit; *No = Medication is available via pharmacy

HCPCS mapping row

Row componentsHCPCS Code; GPI; Drug Name; Generic Name/Code Description; HIM Formulary; Group Value/Group Choice Formulary

Example HCPCS mappingJ0282 = GPI 35400005002030 = Amiodarone HCl Inj 150 MG/3ML; HIM = Yes; Group = Yes

Example HCPCS mapping (gene therapy)J1411 mapped to multiple GPIs for Hemgenix with HIM = Yes and Group = Yes

Field mapping / column headers

InterpretationEach column corresponds to a specific data element used to indicate routing to medical benefit and formulary status

UsageUsed to display per-line coverage direction and formulary indicators for provider billing decisions

Generic Product Identifier (GPI) used in mappings to HCPCS codes and drug names

GPI identifierGeneric Product Identifier (GPI) is reported for each drug entry and used in mappings to HCPCS codes and drug names (e.g., J0561 = GPI 0110002000E610)

Multiple GPIs per HCPCSSome HCPCS codes map to multiple GPIs/pack sizes (e.g., Hemgenix J1411 entries)

PurposeGPI supports precise product identification for formulary and billing flags

Health Insurance Marketplace formulary indicator (Yes/No)

HIM formulary indicatorHealth Insurance Marketplace (HIM) Formulary indicator shown as 'Yes' or 'No' for each HCPCS/GPI line

ExampleJ0561 Bicillin L-A shows HIM = Yes, Group Value = No

RoleIndicates marketplace formulary inclusion for the listed product

HCPCS Code

HCPCS codeUnique HCPCS/J-code used to identify the billed medication or product (e.g., J3380, J9155)

Example formatJ1411 (Hemgenix), J0561 (Bicillin L-A), J9050 (BiCNU)

UseUsed to determine billing direction (medical benefit) and link to GPI and formulary flags

HIM Formulary

HIM formulary flag columnHIM Formulary column indicates whether item is on the Health Insurance Marketplace formulary (Yes/No)

Group formulary columnGroup Value/Group Choice Formulary column indicates group-level formulary inclusion (Yes/No)

Example entriesL8604 Deflux shows HIM = Yes, Group = No; J1411 Hemgenix shows HIM = Yes, Group = Yes

medical-benefit directed medication list (advisory)

Advisory noteThis list does not guarantee coverage; drugs may be subject to coverage requirements or limits such as prior authorization; refer to formulary or plan documents

Provider actionCheck plan/formulary and prior authorization requirements even when item is listed as directed to medical benefit

ScopeList is advisory and used to guide billing to medical benefit but is not an authorization by itself

HCPCS Code, Medications Directed to Medical Benefit

Entry elementsEach entry includes: HCPCS Code; GPI; Drug Name; Generic Name/Code Description; HIM Formulary (Yes/No); Group Value/Group Choice Formulary (Yes/No)

Example row contentJ1411 = GPI 8510253025C635 = Hemgenix = Etranacogene Dezaparvovec-drlb IV Susp 35 x 10 ML Pack; HIM = Yes; Group = Yes

Multiple pack sizesSome HCPCS codes list multiple GPIs/pack sizes, each with its own formulary flags

Medications Directed to Medical Benefit

Directed to medical benefit examplesMultiple HCPCS/J-codes and immune globulin codes are shown as directed to medical benefit (e.g., J9155 Firmagon; 90283 immune globulins)

Formulary flags presentEntries include HIM and Group Value formularies to indicate marketplace and group coverage status

Billing implicationItems listed should be billed to the member's medical benefit when administered by a health care professional

Health Insurance Marketplace (HIM) Formulary indicator used in the list to show marketplace formulary inclusion

HIM indicator usageHIM/Formulary indicator used in the list to show marketplace formulary inclusion (Yes/No) per HCPCS/GPI row

Group formulary variationGroup Value/Group Choice Formulary may be No even when HIM = Yes (examples present)

Decision supportUse indicators to confirm marketplace vs. group formulary status for coverage checks

Indicator showing whether the drug is on the group value/group choice formulary

Group formulary indicatorGroup Value/Group Choice Formulary column indicates whether the product is on the group-level formulary (Yes/No)

ExampleJ3490 (Bupivacaine with epinephrine) shows HIM = Yes but Group = No for some GPIs

InterpretationGroup-level formulary differs from HIM; check both flags when assessing coverage

Generic Product Identifier reported for each drug entry

GPI reported per drugGeneric Product Identifier (GPI) is provided for each drug entry (e.g., J0561 = 0110002000E610)

Multiple GPIs exampleSome HCPCS codes include multiple GPIs for different strengths/pack sizes (see J1411 Hemgenix entries)

PurposeGPI enables matching to formulary and helps determine per-product formulary flags

Indicates whether the product is on the marketplace formulary

Marketplace formulary flag meaningIndicates whether the product is on the Health Insurance Marketplace (HIM) formulary (Yes/No) for that HCPCS/GPI line

Example usageJ1200 Diphenhydramine shows HIM = Yes and Group = No in an entry

Check both flagsConfirm both HIM and Group Value flags when verifying coverage for a given plan

HCPCS table header mapping

Standard layoutThe table header mapping is consistent across the list to present per-line formulary and billing direction information

Intended useSupports provider billing decisions and formulary checks

Medications Directed to Medical Benefit entry format

Entry format summaryMedications Directed to Medical Benefit entries show HCPCS Code / GPI / Drug Name / Generic Description / HIM Formulary / Group Value flags

Multiple rows per productProducts with multiple pack sizes or GPIs are listed as separate rows with individual flags

Medications Directed to Medical Benefit

Directed-to-medical-benefit scopeList contains many HCPCS/J-codes and A/C codes that are directed to the medical benefit and include formulary flags

Examples of therapiesIncludes immune globulins, oncology infusions, contrast agents, gene therapies (Hemgenix), and other injectable/infusible products

Billing actionThese items should be billed to medical benefit when administered by a health care professional; confirm prior auth requirements

Coverage note / prior authorization

Coverage / prior authorization noteDrugs may be subject to coverage requirements or limits such as prior authorization; refer to formulary or plan documents for additional information

List limitationThis list does not guarantee coverage

Provider recommendationVerify plan-specific prior authorization and coverage rules even if item is listed as directed to medical benefit

coverage advisory

Coverage advisoryThe listing is advisory: presence on the list directs billing to medical benefit but does not confirm coverage; coverage may require prior authorization or be limited

ActionConsult formulary/plan documents for definitive coverage and authorization guidance

Examples presentMultiple entries across the list repeat this advisory alongside groups of HCPCS/GPI rows

HIM/Formulary flags

HIM / Formulary flags (summary)Health Insurance Marketplace (HIM) Formulary and Group Value/Group Choice Formulary flags are shown as Yes/No per HCPCS/GPI row to indicate marketplace and group formulary status

Per-row granularityEach product/pack size (GPI) is listed with its own HIM and Group Value flags (e.g., Hemgenix multiple GPIs)

Use for verificationProviders should use these flags along with plan documents to verify coverage and billing direction

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedications Restricted to Medical Benefit

Policy CodePolicy N/A

Change TypeNo material change / informational list

Effective DateN/A

Next Review DateN/A

Key ActionCheck plan/formulary and obtain prior authorization when required before billing medications to the medical benefit.

SourceLink

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