ModifiedBlue Cross Blue Shield - New MexicoPolicy N/A

2023 Specialty Drugs Prior Authorization List for Administrative Services Only Members

Lists prior authorization requirements and management delegation for specialty and provider-administered drugs for ASO members, indicating whether BCBSNM or Carelon manages PA reviews for specific codes and noting effective/add dates.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2023 Specialty Drugs Prior Authorization List for Administrative Services Only Members

Policy CodePolicy N/A

Change TypeDelegation and code additions (Carelon assignmentmultiple code effective dates)

Effective DateSEPTEMBER 18, 2023 (as noted)

Next Review DateN/A

Key ActionSend PA requests to BCBSNM for provider-administered therapy/infusion site of care; send PA requests to Carelon for medical oncology when supported by an oncology diagnosis.

SourceLink

POLICY UPDATE CHANGES

Multiple drug codes (e.g., J9347, J9380, J9228, J9380, J9380 etc.) were added with effective dates (examples: 07/01/2023, 01/01/2023, 04/01/2023).

Prior authorization review responsibility for many codes moved to Carelon (with some exceptions where BCBSNM retains review).

Specific drugs (Unituxin/dinutuximab and Alymsys/bevacizumab-maly) were added effective 01/01/2023 to several miscellaneous codes (e.g., C9399, J3490, J3590, J9999).

Carelon will review requests for oncology drugs supported by an oncology diagnosis effective 04/01/2023.

Prior authorization for code J9325 moved from BCBS to Carelon effective 01/01/2023.

Multiple J-, Q-, and S- codes added to prior authorization requirement and/or added to Small Groups/Mid-Markets or Large Groups with effective dates (various 10/01/2023 and 01/01/2023).

CarelonPrimary PA reviewer for most oncology drugs

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.

~150+Listed HCPCS/J/Q codes in excerpt

10/01/2023Additions on

2023-04-01Carelon review effective

2023-01-01J9325 move effective

Prior Authorization Routing and Coverage Criteria

inv-01: Prior authorization routing and delegation criteria

Routing rules for prior authorization (PA) review based on drug indication and code-level delegation.

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

Send PA requests to Carelon for Medical Oncology & Supportive Care unless the drug requested has multiple indications.

Carelon will only review requests for oncology drugs that are supported by an oncology diagnosis; if the drug requested is not associated with an oncology diagnosis, BCBSNM will review the request.

Refer to the Update History / Prior Authorization Delegation Notes for code‑level effective/add/replacement dates and delegation details.

inv-02: PA routing and coverage rules

Prior authorization review and coverage routing rules in this excerpt:

Carelon will review prior authorization requests for oncology drugs that are supported by an oncology diagnosis.

If the drug requested is not associated with an oncology diagnosis, the request will be reviewed by BCBSNM.

Several codes had prior authorization review moved from BCBSNM to Carelon effective 01/01/2023; prior authorization is required for those codes as noted in the listing.

Many specific HCPCS/J/Q codes listed require prior authorization through Carelon unless otherwise specified as BCBSNM in the listing; follow the code‑level 'Managed By' designation for reviewer assignment.

Some miscellaneous codes were updated to include new drugs effective 01/01/2023 (examples: Unituxin/dinutuximab and Alymsys/bevacizumab‑maly); consult the update history for details.

inv-03: Prior authorization stance and routing

Prior authorization requirement and reviewer assignment for listed codes; market applicability noted where provided.

Prior authorization is required for the listed provider‑administered drug HCPCS/CPT/J/Q/S codes.

Reviewer assignment

Carelon will review requests for oncology drugs that are supported by an oncology diagnosis (Carelon review effective 04/01/2023 for many codes as noted).
BCBSNM will review requests when the drug is not associated with an oncology diagnosis or when the code listing indicates 'Managed By = BCBSNM'.

Some codes had prior authorization responsibility moved from BCBSNM to Carelon effective 01/01/2023 (example: J9325) — follow the code entry for the effective date and current 'Managed By' assignment.

HCPCS/CPT/J/Q/S Codes Subject to Prior Authorization

Examples of listed codes and managementCPT

J9029	Adstiladrin (Inj) - Managed By BCBSNM
C9094	Sutimlimab-Jome 10 mg - Managed By BCBSNM (Code termed 10/01/2022; replaced with J1302)

Infusion/oncology codes with delegation notesmixed

Q5103	Inflectra - Prior Authorization required through BCBSNM (Add to Small Groups/Mid-Markets 10/01/2023)
C9142	Alymsys (Bevacizumab-Maly) - Medical Oncology & Supportive Care; Carelon (added 01/01/2023; later replaced with Q5126 on 04/01/2023)

Selected added/replaced oncology drug codesCPTCovered

J9347	Inj Tremelimumab-Actl 1 Mg
J9380	Inj Teclistamab Cqyv 0.5 Mg
J9228	Yervoy (Ipilimumab)
J9999	Miscellaneous - includes Unituxin (Dinutuximab) and Alymsys (Bevacizumab-Maly)

Immunoglobulin administration codes added to Small Groups/Mid-MarketsCPTCovered

90283	Human Ig IV
90284	Human Ig SC

Provider-administered drug HCPCS/CPT/J/Q/S codes subject to PAmixedCovered

J9312	Rituximab 10 mg / Releuko 1 mcg (provider-administered drug)
J9325	Talimogene Laherparepvec injection
J0202	Alemtuzumab injection
J0585	OnabotulinumtoxinA injection
J1428	Eteplirsen 10 mg injection
J2941	Somatropin injection
Q2041	Axicabtagene ciloleucel
Q2042	Tisagenlecleucel
Q2053	Brexucabtagene autologous CAR-T
Q2054	Lisocabtagene maraleucel CAR-T

1–10 of 14

1/2

General effective date threshold

Effective datePrior authorization requirements effective September 18, 2023 unless otherwise noted in the update history

Document updateUpdated January 2023 to reference changes through January 2024

Exception handlingFollow per‑code Update History / Prior Authorization Delegation Notes where dates differ from the general effective date

effective_date_for_replacement

Replacement effective datesSome code replacements/additions have effective dates of 04/01/2023 or 07/01/2023 depending on the code (e.g., Q5126 added effective 04/01/2023 replacing C9142; other Q‑codes note Add effective 07/01/2023)

What Providers Must Do / Where to Send Prior Authorization Requests

Prior Authorization

Prior Authorization Submission Routing and Delegation

Send prior authorization (PA) requests to the appropriate reviewer based on the drug, code, and diagnosis. Carelon Medical Benefits Management (Carelon) reviews requests for Medical Oncology & Supportive Care — but only for oncology drugs supported by an oncology diagnosis. Blue Cross Blue Shield of New Mexico (BCBSNM) reviews PA requests for provider-administered therapy or infusion site of care and will review requests for drugs not associated with an oncology diagnosis. Refer to code-level notes below for which entity manages PA for specific HCPCS/CPT codes.

Carelon reviews Medical Oncology & Supportive Care prior authorization requests for oncology drugs when supported by an oncology diagnosis.
BCBSNM reviews prior authorization requests for provider-administered therapy, infusion site of care, and any drug requests that are not associated with an oncology diagnosis.
Some codes have multiple indications; when a code/drug has multiple indications Carelon will only review oncology indications — non-oncology indications will be reviewed by BCBSNM.

Note

PA Effective Date Note

Prior authorization requirements in this document are effective on September 18, 2023 unless a different effective date is specified in the update history for a particular code or drug.

Key Terms and Parties

Carelon

Vendor nameCarelon Medical Benefits Management

RolePer document, 'Carelon Medical Benefits Management = Med Oncology & Supportive Care'

Review scopeCarelon will review prior authorization requests for oncology drugs that are supported by an oncology diagnosis

Managed By

Definition'Managed By' indicates which entity (BCBSNM or Carelon) handles prior authorization for the listed code/drug

Usage exampleJ9029 Managed By = BCBSNM (provider administered drug therapy)

Usage example

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2023 Specialty Drugs Prior Authorization List for Administrative Services Only Members

Policy CodePolicy N/A

Change TypeDelegation and code additions (Carelon assignmentmultiple code effective dates)

Effective DateSEPTEMBER 18, 2023 (as noted)

Next Review DateN/A

Key ActionSend PA requests to BCBSNM for provider-administered therapy/infusion site of care; send PA requests to Carelon for medical oncology when supported by an oncology diagnosis.

SourceLink

On This Page

Certain codes include market applicability additions (e.g., added to Small Groups/Mid‑Markets or Large Groups with effective dates such as 10/01/2023 or 01/01/2023); follow the listing for group/market applicability per code.

Follow update historyUse the per‑code 'Add effective' or 'Code Termed/replace' entries to determine the exact replacement date for each code

Fallback review ruleIf not otherwise noted, the general PA effective date (09/18/2023) applies to codes without explicit replacement/add dates

Note

Code-level Management Notes

Code-level management notes indicate which entity (Managed By = BCBSNM or Carelon) is responsible for prior authorization review for each specific HCPCS/CPT code. Review the code entries for delegation details and any update-history notes (including effective dates when responsibility moved).

Entries list the code, category (e.g., Provider Administered Drug Therapy, Infusion Site of Care), drug product name, Managed By (BCBSNM or Carelon), and Update History / Delegation Notes.
When a code has multiple indications the list will highlight this; Carelon only reviews requests supported by an oncology diagnosis.
Some prior authorization responsibilities moved from BCBSNM to Carelon effective 01/01/2023 (see specific codes below).

Prior Authorization

J9325 Prior Authorization Routing

J9325 (Talimogene Laherparepvec) prior authorization routing: effective 01/01/2023 the PA review responsibility moved from BCBSNM to Carelon. Prior authorization is required; Carelon will review requests for this oncology drug when supported by an oncology diagnosis.

J9325 — Managed By: Carelon. Update history: Effective 01/01/2023, prior authorization move from BCBS to Carelon. Prior authorization required.

Prior Authorization

Provider-administered Drug Prior Authorization List (BCBSNM-managed Codes)

The following provider-administered drug codes require prior authorization through BCBSNM (Managed By = BCBSNM) unless otherwise noted in the code-level entry. This consolidated list reflects codes explicitly marked as BCBSNM-managed in the source and includes examples where BCBSNM remains the PA reviewer.

90283 — Human Ig IV — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
90284 — Human Ig SC — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
90378 — RSV Mab IM 50Mg — Managed By: BCBSNM — Prior Authorization required.
C9257 — Bevacizumab Injection — Managed By: BCBSNM — Prior Authorization required.
J0202 — Alemtuzumab Injection — Managed By: BCBSNM — Prior Authorization required.
J0565 — Bezlotoxumab 10 Mg — Managed By: BCBSNM — Prior Authorization required.
J0567 — Cerliponase Alfa 1 Mg — Managed By: BCBSNM — Prior Authorization required (added to Large Groups 10/01/2023).
J0585 / J0586 / J0587 / J0588 — Botulinum toxin variants — Managed By: BCBSNM — Prior Authorization required (many added to Small Groups/Mid-Markets 10/01/2023).
J0775 — Collagenase Clostridium Histolyticum Injection — Managed By: BCBSNM — Prior Authorization required.
J0888 — Epoetin Beta (non-ESRD) — Managed By: BCBSNM — Prior Authorization required.
J1325 — Epoprostenol Injection — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J1411 — Hemgenix per Tx Dose — Managed By: BCBSNM — Add effective 10/01/2023.
J1428 — Eteplirsen 10 Mg — Managed By: BCBSNM — Prior Authorization required.
J1562 — Vivaglobin Injection — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J1675 — Histrelin Acetate — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J1726 — Makena 10 Mg — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J1950 — Leuprolide Acetate 3.75 Mg — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J2278 — Ziconotide Injection — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J2326 — Nusinersen 0.1 Mg — Managed By: BCBSNM — Prior Authorization required.
J2502 — Pasireotide Long Acting — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J2562 — Plerixafor Injection — Managed By: BCBSNM — Prior Authorization required.
J2941 — Somatropin Injection — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J3121 / J3145 — Testosterone formulations — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J3285 — Treprostinil Injection — Managed By: BCBSNM — Prior Authorization required.
J3315 — Triptorelin Pamoate — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J3398 / J3399 — Gene/cell therapies and related injections — Managed By: BCBSNM — Prior Authorization required.
J7178 — Human Fibrinogen Concentrate — Managed By: BCBSNM — Prior Authorization required.
J7340 — Carbidopa-Levodopa ENTERAL — Managed By: BCBSNM — Prior Authorization required.
J9155 — Degarelix Injection — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
J9202 / J9217 / J9218 / J9219 — Leuprolide/Goserelin implants or injections — Managed By: BCBSNM — Prior Authorization required (many added to Small Groups/Mid-Markets 10/01/2023).
J9225 / J9226 — Vantas / Supprelin LA Implants — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).
Q2041 / Q2042 / Q2053 / Q2054 / Q2055 / Q2056 — CAR-T therapies — Managed By: BCBSNM — Prior Authorization required (Q2056 added effective 01/01/2023).
S0157 / S0189 — Becaplermin Gel; Testosterone Pellet — Managed By: BCBSNM — Prior Authorization required (added to Small Groups/Mid-Markets 10/01/2023).

J9325 Managed By = Carelon (moved effective 01/01/2023)

ASO members

AudienceAdministrative Services Only (ASO) members

Document scopePA list applies specifically to ASO members of Blue Cross Blue Shield of New Mexico

Action for providersProviders serving ASO members must follow the PA routing and delegation noted in this document

Carelon (vendor assigned to perform prior authorization review for many oncology drugs)

Short definitionCarelon: vendor assigned to perform prior authorization review for many oncology drugs (Carelon Medical Benefits Management)

Review conditionCarelon will only review oncology drug requests that are supported by an oncology diagnosis

Delegation noteCarelon handles Medical Oncology & Supportive Care per the PA list entries

Blue Cross Blue Shield of New Mexico

Payer identityBlue Cross Blue Shield of New Mexico (BCBSNM)

Review roleBCBSNM reviews PA requests for Provider Administered Therapy or Infusion Site of Care and reviews requests when the drug is not associated with an oncology diagnosis

Delegation exceptionsSome codes remain under BCBSNM review even when others moved to Carelon; see code‑level entries for details

Prior Authorization routing

Routing rulePrior Authorization required and routed to BCBSNM or Carelon depending on the code and whether the request is supported by an oncology diagnosis

Provider admin/infusionSend PA requests to BCBSNM for Provider Administered Therapy or Infusion Site of Care

Oncology/supportive careSend PA requests to Carelon for Medical Oncology & Supportive Care unless the drug has multiple indications; Carelon reviews oncology‑diagnosis‑supported requests