CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2023 Specialty Drugs Prior Authorization List for Fully Insured and ASO Members

Defines prior authorization requirements and delegated review responsibilities for provider-administered specialty drugs and infusion site of care for BCBSNM fully insured and ASO members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2023 Specialty Drugs Prior Authorization List for Fully Insured and ASO Members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionSend prior authorization requests to BCBSNM for provider-administered therapy or infusion site of care; send oncology-supported requests to Carelon for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=30number of drug/codes entries in this part

Jan 1, 2023effective date for PA requirements

Carelononcology reviews delegated to

10/01/2023adds to Small/Mid-Markets

~120HCPCS/CPT entries shown

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization Coverage Criteria & Routing

inv-01: PA routing and applicability

Prior authorization routing and managerial responsibility

Prior Authorization is required for the listed provider‑administered and infusion site codes.

Send prior authorization (PA) requests to BCBSNM for provider‑administered therapy or infusion site of care.

Send PA requests to Carelon (formerly AIM Specialty Health) for medical oncology and supportive care requests unless the drug requested has multiple indications.

Carelon will only review requests that are supported by an oncology diagnosis; requests not supported by an oncology diagnosis will be reviewed by BCBSNM.

inv-02: Prior authorization required with vendor routing — Coverage action for listed codes

Coverage action for listed codes

Prior Authorization required for the listed J‑, Q‑ and other HCPCS/CPT codes.

Reviewer assignment

Carelon will review requests for codes assigned to Medical Oncology & Supportive Care (Carelon-managed).
BCBSNM will review requests for codes assigned to Provider Administered Therapy or Infusion Site of Care (BCBSNM-managed).
Some individual code entries specify 'Carelon or BCBSNM' — check the specific code entry for reviewer assignment before submission.

Effective dates or 'Add effective' notes are present on multiple code entries; providers must observe the effective date noted for each code.

inv-03: Prior authorization routing and submission rules

Routing and authorization criteria based on drug code and diagnosis association:

If the requested drug/code is assigned as an oncology drug and the request is supported by an oncology diagnosis, Carelon will review the prior authorization request.

If the requested drug/code is not associated with an oncology diagnosis, BCBSNM will review the prior authorization request.

Certain codes explicitly require prior authorization through BCBSNM irrespective of oncology routing — see specific code entries (examples listed in code group entries).

Some codes are marked 'Carelon or BCBSNM' — providers must check the specific code entry for reviewer assignment prior to submission.

Operational note

Preauthorization or eligibility verification is not a guarantee of payment; final benefits are determined at claim adjudication.

HCPCS / J-codes, Q-codes and Code Changes

Sample J-codes in listHCPCS

J0129	Example code referenced for provider-administered therapy / infusion site of care
J0180	Fabrazyme (Agalsidase Beta) — listed
J0221	Lumizyme (Alglucosidase Alfa) — listed

Additional J-code entries from listHCPCS

J1322	Soliris (Eculizumab) = Vimizim (Elosulfase Alfa) — Infusion Site of Care; Prior Authorization required through BCBS
J1458	Soliris (Eculizumab) = Naglazyme (Galsulfase) — Infusion Site of Care; Prior Authorization required through BCBS

Sample Q-codesHCPCS

Q5103	Mepsevii (Vestronidase Alfa-Vjbk) = Inflectra (Infliximab-Dyyb); Infusion Site of Care; Prior Authorization required through BCBS
Q5104	Mepsevii (Vestronidase Alfa-Vjbk) = Renflexis (Infliximab-Abda) - Non-Preferred; Infusion Site of Care; Prior Authorization required through BCBS

Examples of HCPCS/Q-codes and J-codes in listmixed

Q5103	Infusion Site of Care; Prior Authorization required through BCBS
J1459	Injection, Immune Globulin (Privigen), Intravenous, 500 Mg — Infusion Site of Care; BCBSNM = Carelon or BCBSNM; Prior Authorization required through BCBS

Code replacements/termingmixed

J1302	Inj, Sutimlimab-Jome, 10 Mg — Add Effective 07/01/2023 (replaces C9094)
C9094	Inj Sutimlimab-Jome 10 Mg — Code termed 10/01/2022; replaced with J1302

Sample oncology J-codes routed to CarelonHCPCSCovered

J9043	Multiple oncology/supportive care drugs — Prior Authorization required through Carelon
J9063	Elahere (Mirvetuximab) — Add Effective 7/1/2023; Carelon will review requests for oncology drugs supported by an oncology diagnosis

Provider-administered drugs routed to BCBSNMHCPCSCovered

J0202	Alemtuzumab — Provider Administered Drug Therapy; Prior Authorization required through BCBSNM
J2326	Spinraza (Nusinersen) — Provider Administered Drug Therapy; Prior Authorization required through BCBSNM

Effective additions for Small Groups/Mid-Markets

Effective date of additionsMany codes added to Small Groups/Mid-Markets effective 10/01/2023

Affected group typesSmall Groups and Mid-Markets

Scope of additionsMultiple HCPCS/J/Q codes and infusion-related CPT entries added

Reference guidanceSee individual code entries on the PA list for exact add-to-group notes and effective dates

What Providers Must Do / Where to Submit Authorization Requests

Prior Authorization

Where to send prior authorization requests

Send prior authorization (PA) requests to BCBSNM for provider‑administered therapy or when the request is for infusion site of care. Send PA requests to Carelon (formerly AIM) for medical oncology and supportive care drugs when indicated.

Prior Authorization required through BCBSNM for listed provider‑administered drugs and infusion site CPT/HCPCS codes.
Carelon will review oncology/supportive care drug requests that are supported by an oncology diagnosis; if the drug requested is not associated with an oncology diagnosis, BCBSNM will review.
Some codes/drugs are routed as "Carelon or BCBSNM"—providers must check the specific code routing on the PA list to determine which reviewer to submit to.

Prior Authorization

Prior authorization requirements and group additions

Several J‑ and Q‑codes and other provider‑administered drugs require prior authorization through BCBSNM; many of these were added to Small Groups/Mid‑Markets effective 10/01/2023. For oncology drugs and related supportive‑care J‑codes, Carelon is the designated reviewer when the request is oncology‑related.

Key Terms & Vendor Names

Carelon — Carelon (formerly AIM Specialty Health)

OrganizationCarelon Medical Benefits Management (formerly AIM Specialty Health)

RoleDelegated reviewer for medical oncology & supportive care prior authorization requests when supported by an oncology diagnosis

Review limitationCarelon will only review requests that are supported by an oncology diagnosis; drugs with multiple indications may be routed differently

Submission noteSend PA requests for medical oncology & supportive care to Carelon unless code entry specifies BCBSNM or 'Carelon or BCBSNM'

Infusion Site of Care — category indicating provider-administered/infused therapies that require PA

DefinitionInfusion Site of Care — category indicating provider-administered/infused therapies that require prior authorization

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2023 Specialty Drugs Prior Authorization List for Fully Insured and ASO Members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionSend prior authorization requests to BCBSNM for provider-administered therapy or infusion site of care; send oncology-supported requests to Carelon for review.

SourceLink

On This Page

Prior Authorization required through BCBSNM for listed J‑ and Q‑codes (see code list).
Effective 10/01/2023: many codes were added to Small Groups/Mid‑Markets.
Carelon reviews oncology drugs supported by an oncology diagnosis; otherwise BCBSNM reviews.

Note

Mixed reviewer routing (Carelon or BCBSNM)

Some codes are routed to Carelon, some to BCBSNM, and some are listed as "Carelon or BCBSNM." When a code is designated "Carelon or BCBSNM," Carelon will review requests that are supported by an oncology diagnosis; if not oncology‑related, BCBSNM will review the request. Providers should verify routing for each specific code on the PA list before submission.

Codes marked "Carelon": submit to Carelon (medical oncology & supportive care).
Codes marked "BCBSNM": submit to BCBSNM (provider‑administered therapy / infusion site).
Codes marked "Carelon or BCBSNM": Carelon reviews when an oncology diagnosis supports the request; otherwise BCBSNM reviews.

Typical routingEntries marked 'Infusion Site of Care' often indicate PA required through BCBSNM (provider administered) unless otherwise noted

ExamplesCodes such as J1322, Q5103 and many J-/Q-codes are labeled 'Infusion Site of Care' in the PA list

Prior Authorization — Prior Authorization required through BCBS

RequirementPrior Authorization required through BCBS (BCBSNM) for listed provider-administered drugs and infusion site CPT/HCPCS codes

Where to send requestsSend PA requests to BCBSNM for provider-administered therapy or infusion site of care

Vendor routingSome codes are delegated to Carelon for medical oncology & supportive care; check individual code entry for reviewer

Effective datePA requirements effective Jan 1, 2023 unless an entry notes a different add/effective date

Carelon — Carelon will review oncology drugs when supported by an oncology diagnosis; otherwise BCBS reviews.

Routing ruleCarelon will review requests for oncology drugs when the request is supported by an oncology diagnosis

Non-oncology requestsIf the drug requested is not associated with an oncology diagnosis, BCBSNM will review the request

Multiple indicationsFor drugs with multiple indications, Carelon will only review oncology-supported indications; otherwise BCBS handles review

Carelon review rule — Carelon will review requests for oncology drugs supported by an oncology diagnosis; non-oncology diagnoses are reviewed by BCBSNM

Review assignment ruleCarelon will review requests for oncology drugs supported by an oncology diagnosis; non-oncology diagnoses are reviewed by BCBSNM

'Carelon or BCBSNM' entriesSome codes list 'Carelon or BCBSNM'—check the specific code entry for final reviewer assignment

Action for providersVerify diagnosis coding and the code-specific reviewer before submitting PA to ensure correct routing

Availity — Availity is a third-party health information network used for electronic information exchange; BCBS makes no endorsement of third-party vendors

Service descriptionAvaility is a third-party health information network that provides electronic information exchange services to medical professionals

Relationship to BCBSAvaility provides administrative services to BCBSOK; it is a separate company and not endorsed by BCBSNM

DisclaimerBCBS makes no endorsement, representations or warranties regarding products or services offered by third-party vendors such as Availity; contact the vendor directly with questions