ModifiedBlue Cross Blue Shield - New MexicoPolicy N/A

ASO Specialty Pharmacy prior authorization code list

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Lists procedure/drug codes that require prior authorization for BCBSNM ASO members (medical benefit specialty pharmacy) and indicates which manager (BCBSNM or Carelon) handles each request.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyASO Specialty Pharmacy prior authorization code list

Policy CodePolicy N/A

Change TypeAdds, retires, and routing clarifications

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionVerify member eligibility and request prior authorization through BCBSNM or Carelon as indicated before providing the service.

SourceLink

POLICY UPDATE CHANGES

Multiple J- and Q- codes were added with effective dates 01/01/2024 or 04/01/2024 and flagged as requiring prior authorization through Carelon.

Several codes are marked retired effective 04/01/2024.

Codes representing unclassified drugs/biologics (C9399, J3490, J3590, Q2043, Q2050, etc.) require prior authorization through Carelon.

manyprocedure/drug codes listed requiring prior authorization

20+codes requiring Carelon prior authorization in extract

≥4codes added effective 04/01/2024 in this extract

4codes retired effective 04/01/2024 in this extract

01/01/2024base effective date

Codes Requiring Prior Authorization & Coverage Rules

Prior authorization code criteria (examples)

Prior authorization is required for the following example codes; some entries include effective dates and manager assignments.

C9163 — Talvey (Talquetamab‑Tgvs); Managed by Carelon; Add Effective 04/01/2024; to be replaced by J3055 effective 07/01/2024; Prior Authorization required through Carelon.

J3055 — Inj Talquetamab‑Tgvs 0.25 mg; Managed by Carelon; Add Effective 07/01/2024 (replaces C9163 7/1/24); Prior Authorization required through Carelon.

C9165 — Elrexfio (Elranatamab‑Bcmm); Managed by Carelon; Add Effective 07/01/2024; Prior Authorization required through Carelon.

J1323 — Inj Elranatamab‑Bcmm 1 mg; Managed by Carelon; Add Effective 04/01/2024; Prior Authorization required through Carelon.

J0741 — Inj Cabotegravir Rilpivir (provider administered drug therapy); Managed by BCBSNM; Add Effective 07/01/2024; Prior Authorization required through BCBSNM.

J1961 — Inj Lenacapavir 1 mg; Managed by BCBSNM; Add Effective 07/01/2024; Prior Authorization required through BCBSNM.

J1551 — Infusion site example; Managed by Carelon or BCBSNM; Carelon will review requests supported by an oncology diagnosis; non‑oncology indications will be reviewed by BCBSNM; Prior Authorization required.

Carelon prior authorization requirement

The following codes are assigned to Medical Oncology & Supportive Care and require prior authorization through Carelon unless otherwise noted.

J0642 — Prior Authorization required through Carelon (Medical Oncology & Supportive Care).

J0882 — Prior Authorization required through Carelon (Medical Oncology & Supportive Care).

J0896 — Prior Authorization required through Carelon (Medical Oncology & Supportive Care).

J0897 — Prior Authorization required through Carelon (Medical Oncology & Supportive Care).

J9022 — Prior Authorization required through Carelon (Atezolizumab 10 mg).

J9271 — Prior Authorization required through Carelon (Pembrolizumab).

J9302 — Prior Authorization required through Carelon (Ofatumumab/Obinutuzumab group).

BCBSNM prior authorization routing

Some Q- and related codes require prior authorization through BCBSNM.

Q5104 — Prior Authorization required through BCBSNM (Renflexis injection).

Q5121 — Prior Authorization required through BCBSNM (Avsola injection).

Q5109 — Prior Authorization required through BCBSNM (infusion site examples noted elsewhere).

Retired codes (operational)

The following codes are retired and should not be submitted for authorization on or after the effective retire date.

J9037 — Inj Belantamab Mafodont (Carelon) — Retire Effective 04/01/2024; do not submit for authorization after 2024-04-01.

J9313 — Inj Lumoxiti 0.01 mg (Carelon) — Retire Effective 04/01/2024; do not submit for authorization after 2024-04-01.

J9057 — (listed among retired examples in summary) — Retire Effective 04/01/2024; do not submit for authorization after 2024-04-01.

Q2049 — Code noted as retired Effective 04/01/2024; do not submit for authorization after 2024-04-01.

Coverage and authorization notes

General coverage guidance and operational limits related to prior authorization.

Presence of a code on the prior authorization list does not guarantee coverage; member benefits and eligibility determine coverage.

Providers are usually responsible for requesting prior authorization before performing a service for in‑network members; some plans may require the member to request PA.

Once a prior authorization request is received and processed, the decision will be communicated to the provider; call the PA number on the member's ID card for questions.

Checking eligibility/benefits and prior authorization is not a guarantee of payment; final payment is determined at claim adjudication based on member eligibility and certificate of coverage on date of service.

This list is not exhaustive; codes may change and the list may be updated throughout the year.

Coverage and prior authorization notes

Coverage and prior authorization requirements depend on the member's benefits and eligibility; inclusion on this list does not imply benefit coverage.

Verify member eligibility and benefits via Availity or the preferred vendor portal before assuming coverage or submitting a prior authorization request.

Certain listed codes require prior authorization through BCBSNM or through contracted vendors (for example, Carelon) before services are rendered.

For some services/members, prior authorization may be managed by Blue Cross and Blue Shield of MT or by Carelon Medical Benefits Management per contractual arrangements; check routing before submitting PA.

HCPCS / J / Q / S Codes and Status

Infusion Site of Care examplesmixedCovered

J0485	Belatacept Injection
J0491	Anifrolumab-Fnia (Inj)

Unclassified drug codeHCPCSCovered

C9399

Unclassified drugs/biologics (Code represents unclassified drugs or biologics)

Selected oncology/supportive-care J-codesHCPCSCovered

J9022	Atezolizumab 10 mg injection
J9271	Pembrolizumab injection
J9302	Ofatumumab injection

Unclassified drug/biologic codesHCPCSCovered

C9399	Unclassified drugs or biologics
Q2043	Code represents unclassified drugs or biologics (Provenge example)

Q-code group — oncology/supportive caremixed

Q2043	Unclassified drugs/biologics — prior authorization required through Carelon
Q2049	Code noted as retired effective 04/01/24
Q2050	Doxorubicin Inj 10Mg — prior authorization required through Carelon

J-code group — gene therapies and high-cost provider-administered drugsmixed

J1411	Hemgenix — added effective 01/01/2024; prior authorization required through BCBS
J1412	Roctavian — added effective 04/01/2024; prior authorization required through BCBS
J1413	Delandistrogene mox — added effective 04/01/2024; prior authorization required through BCBS

sample HCPCS S-codes listedHCPCS

S0157	0.5 Gm. — Prior Authorization required through BCBS
S0189	Goserelin Acetate Implant / Testosterone Pellet 75 Mg — Prior Authorization required through BCBS

Code replacement effective date

Effective replacement dateSome C-codes (e.g., C9163) are scheduled to be replaced by J-codes (e.g., J3055) on 07/01/2024.

Example mappingC9163 to be replaced by J3055 on 07/01/2024.

Manager for replacementsReplaced codes retain the same manager assignment (Carelon where indicated).

Codes added with effective dates in this extract

Adds effective 01/01/2024J9350 is listed as Add Effective 01/01/2024 (prior authorization through Carelon).

Adds effective 04/01/2024Multiple codes (e.g., J9349, J9332, C9163 added 04/01/2024) are shown with Add Effective 04/01/2024 annotations.

Adds effective 07/01/2024Several codes (e.g., J3055, J0741, J1961) show Add Effective 07/01/2024 in the list.

Exhaustiveness

Non-exhaustive listThis is not an exhaustive list of all codes; codes may change and the list may be updated throughout the year.

Validate coveragePresence on the list does not guarantee coverage; always verify member benefits and eligibility.

Updates may occurThe list may be revised during the year to add or retire codes; check for the latest version before submission.

What Providers Must Do

Note

Purpose and routing

Use this list to identify procedure codes that may require benefit prior authorization through Blue Cross Blue Shield of New Mexico (BCBSNM) ASO; some oncology drug requests that are supported by an oncology diagnosis are managed by Carelon Medical Benefits Management.

Prior Authorization

Sample code updates (April/July 2024)

The listed codes with Add/Update effective dates (for example C9163, J3055, J0741, J1961) were added or updated in April/July 2024 and require prior authorization through the manager indicated (Carelon or BCBSNM).

C9163 — Managed by Carelon; Add Effective 04/01/2024; to be replaced by J3055 7/1/24 (PA through Carelon).
J3055 — Managed by Carelon; Add Effective 07/01/2024 (PA through Carelon).
J0741, J1961 — Managed by BCBSNM; Add Effective 07/01/2024 (PA through BCBSNM).

Prior Authorization

Oncology routing rule

Carelon will review requests for many infusion/oncology drugs when the request is supported by an oncology diagnosis; if the drug is not associated with an oncology diagnosis, the request will be reviewed by BCBSNM.

Examples: J1551 and J1554 are noted as 'Carelon or BCBSNM' with the oncology-routing rule described.

Prior Authorization

Prior authorization routing (Q/C codes)

Some Q-codes (e.g., Q5104, Q5121) require prior authorization through BCBSNM; unclassified drug codes (e.g., C9399) represent unclassified drugs/biologics and require prior authorization through Carelon.

Q5104, Q5121 — Prior Authorization required through BCBSNM.
C9399 — Code represents unclassified drugs/biologics; Prior Authorization required through Carelon.

Prior Authorization

J-code prior authorization through Carelon

The listed J-codes assigned to Medical Oncology & Supportive Care (examples include J0642, J0882, J0896, J2506 and others) require prior authorization through Carelon.

J0642, J0882, J0896, J0897, J2506, J2820, J2860, J3490, J3590 — Prior Authorization required through Carelon.

Documentation Required

Retired codes (effective 04/01/2024)

Specified codes are retired effective 04/01/2024 and should not be used for prior authorization after that date.

J9037, J9057, J9313, Q2049 — Marked 'Retire Effective 04/01/24.'

Prior Authorization

Prior authorization routing — Carelon

Prior Authorization is required through Carelon for the listed J-codes and their associated specialty drugs (examples include J9354, J9355, J9356, J9358, J9359, J9380).

J9354, J9355, J9356, J9358, J9359, J9380 — Prior Authorization required through Carelon.

Prior Authorization

Prior authorization routing — BCBSNM and Carelon

Prior authorization is required through BCBSNM or Carelon depending on the code and diagnosis; Carelon reviews oncology requests linked to an oncology diagnosis, while non-oncology indications are reviewed by BCBSNM.

Examples: J9035 and codes representing unclassified drugs may be routed to Carelon for oncology indications and to BCBSNM for non-oncology indications.

Prior Authorization

Prior authorization routing — BCBSNM (cell therapies)

Prior authorization is required through BCBSNM for listed Q-codes that represent CAR-T and other cell therapies (examples include Q2041, Q2042, Q2053–Q2056).

Q2041, Q2042, Q2053, Q2054, Q2055, Q2056 — Prior Authorization required through BCBSNM (cell therapies).

Note

Prior authorization request responsibility

Usually, the provider is responsible for requesting prior authorization before performing a service when the member is seeing an in-network provider; in some cases the plan may require the member to request authorization.

Documentation Required

Communication of PA decision and contact

Once a prior authorization request is received and processed, the decision is communicated to the provider; for questions call the prior authorization number on the member's ID card.

Documentation Required

Verify eligibility and benefits

Presence of a code on this list does not guarantee coverage; always verify member eligibility and benefits via Availity® Essentials or your preferred vendor portal before proceeding.

Checking eligibility/benefits and/or prior authorization is not a guarantee of payment; final payment is determined at claim adjudication based on the member's coverage at date of service.

Note

Utilization management vendors

Some prior authorizations may be managed by Carelon Medical Benefits Management or by Blue Cross and Blue Shield of Montana depending on the service and member; Carelon is an independent company contracted to provide utilization management services for BCBSNM.

For services handled by Carelon, call 1-866-455-8415 or access the Carelon website.

Key Terms and Vendor Names

Carelon — Carelon Medical Benefits Management

DefinitionCarelon Medical Benefits Management (Carelon) — an independent company contracted to provide utilization management services for BCBSNM members.

Role in documentCarelon handles prior authorization for certain services, particularly many oncology/supportive-care drugs when supported by an oncology diagnosis.

ContactFor services handled by Carelon, call 1-866-455-8415 or visit the Carelon medical benefits management specialty care web page.

Oncology routing

Routing ruleRequests for oncology drugs supported by an oncology diagnosis are reviewed by Carelon; if not associated with an oncology diagnosis, BCBSNM will review.

Example codesCodes such as J1551 and J1554 are annotated as 'Carelon or BCBSNM' with the oncology-routing note.

Implication for providersIndication/diagnosis on the prior authorization request determines whether Carelon or BCBSNM reviews the request.

Carelon prior authorization

RequirementPrior Authorization required through Carelon for specified codes assigned to Medical Oncology & Supportive Care (e.g., J0642, J2506, J9354).

Provider actionSubmit prior authorization requests to Carelon for codes managed by Carelon as indicated on the list.

Carelon-managed examplesJ0642, J2506, J9349, J9354, and many J-codes in the oncology/supportive-care sections are managed by Carelon.

Unclassified drug/biologic code (C9399, J3490, etc.)

Unclassified drug/biologic codesCodes such as C9399, J3490, J3590, Q2043 represent unclassified drugs or biologics.

MeaningThese codes are used for unclassified drugs/biologics or 'Drugs Unclassified Injection' and may list multiple product examples.

Prior authorization routingUnclassified drug/biologic codes are assigned to Carelon for prior authorization in this document.

Prior authorization

DefinitionPrior authorization — a requirement to obtain approval before services are rendered to confirm medical necessity as defined by the member's health benefit plan.

ResponsibilityUsually the provider is responsible for requesting prior authorization for in-network services; some plans may require the member to request authorization.

Decision communicationOnce processed, the prior authorization decision is communicated to the provider; call the PA number on the member's ID card with questions.

Availity

DefinitionAvaility — an electronic information exchange/portal recommended to check eligibility and benefits prior to requesting services (Availity Essentials / availity.com).

PurposeUse Availity or preferred vendor portal to confirm coverage, prior authorization requirements, and vendor assignment before submitting requests.

Separate entityAvaility is a separate company that provides electronic information exchange and administrative services to BCBSNM.

Prior authorization (purpose and notes)

PurposePrior authorization is required to confirm medical necessity before services are rendered as defined by the member's health benefit plan.

Provider responsibilityProviders are usually responsible for requesting prior authorization for in-network services; check member contract for exceptions.

Not a guarantee of paymentPrior authorization or eligibility checks do not guarantee payment; final determination occurs at claim adjudication based on member coverage on date of service.

Availity (separate company providing services to BCBSNM)

Vendor descriptionAvaility is a separate company that operates a health information network to provide electronic information exchange services to medical professionals.

Role with BCBSNMAvaility provides administrative services to BCBSNM and is used to verify eligibility and benefits.

Provider actionUse Availity Essentials or preferred web vendor portal to confirm member eligibility, benefits, and PA requirements before requesting services.

Independent utilization management vendor (Carelon)

DefinitionAn independent company contracted to provide utilization management and related services for BCBSNM members (Carelon Medical Benefits Management).

ScopeCarelon manages prior authorization for many oncology/supportive-care drugs and other specialty services as contracted by BCBSNM.

Contact and noteFor Carelon-managed services call 1-866-455-8415 or visit Carelon's specialty care web page; BCBSNM disclaims endorsement of third-party vendors.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyASO Specialty Pharmacy prior authorization code list

Policy CodePolicy N/A

Change TypeAdds, retires, and routing clarifications

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionVerify member eligibility and request prior authorization through BCBSNM or Carelon as indicated before providing the service.

SourceLink

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