CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Specialty Drugs Prior Authorization List (ASO members)

A list of specialty (provider-administered/infusion) drugs and HCPCS/J-codes that require prior authorization for Administrative Services Only (ASO) members of Blue Cross Blue Shield of New Mexico; indicates management/delegation between BCBSNM and Carelon (formerly AIM) and notes group applicability and infusion site of care categories.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySpecialty Drugs Prior Authorization List (ASO members)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 18, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests to BCBSNM for provider-administered therapy or infusion site of care and to Carelon for delegated medical oncology and supportive care requests supported by an oncology diagnosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+drug codes listed (J-/Q-/902xx/HCPCS)

2023-09-18PA requirements effective date (unless noted)

Carelondelegated medical oncology & supportive care reviewer

100+unique HCPCS/CPT/Q/C codes listed requiring prior authorization or infusion site review

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Policy Snapshot

This list identifies specialty provider‑administered/infusion drugs and associated HCPCS/J-/Q-/902xx codes that require prior authorization for Administrative Services Only (ASO) members of Blue Cross Blue Shield of New Mexico. It specifies which items are managed directly by BCBSNM and which are delegated to Carelon (formerly AIM) for medical oncology and supportive care reviews, notes group‑specific additions or effective dates where applicable, and flags items designated as Infusion Site of Care where the route or site of administration may affect reviewer routing.

Policy overview

Effective date2023-09-18

Next review

Last review

Policy statusCURRENT

SubjectSpecialty Drugs Prior Authorization List (ASO members)

Scope summaryA list of specialty (provider-administered/infusion) drugs and HCPCS/J-codes that require prior authorization for Administrative Services Only (ASO) members of Blue Cross Blue Shield of New Mexico; indicates management/delegation between BCBSNM and Carelon (formerly AIM) and notes group applicability and infusion site of care categories.

Codes and Billing Categories

Provider-administered specialty drugs and infusion site of care J-/Q- codesHCPCSCovered

J0129	See BCBSNM Medical Policy / provider administered therapy or infusion site of care
J0180	Fabrazyme (Agalsidase Beta) - BCBSNM managed
J0221	Lumizyme (Alglucosidase Alfa) / Onpattro (Patisiran)
J0490	Benlysta (Belimumab)
J0584	Crysvita (Burosumab-Twza)
J0598	Cinryze (C1 Esterase Inhibitor)
J0717	Cimzia (Certolizumab Pegol)
J1290	Kalbitor (Ecallantide)
J1322	Vimizim (Elosulfase Alfa) - infusion site of care
J1458	Naglazyme (Galsulfase)

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Provider administered drugs requiring prior authorization (BCBSNM review)HCPCS|CPT|QCovered

J2502	Signifor Lar (Pasireotide) - Prior Authorization required
J2941	Humatrope, Saizen (Somatropin) - Prior Authorization required
J3121	Testosterone Enanthate - Prior Authorization required
J3145	Aveed (Testosterone Undecanoate) - Prior Authorization required
J3315	Trelstar (Triptorelin Pamoate) - Prior Authorization required
J9155	Firmagon (Degarelix) - Prior Authorization required
J9202	Zoladex (Goserelin Acetate Implant) - Prior Authorization required
J9217	Eligard, Lupron Depot, Lupron Depot-Ped (Leuprolide Acetate, Depot) - Prior Authorization required
J9218	Leuprolide Acetate, Non Depot - Prior Authorization required
J9219	Viadur (Leuprolide Acetate Implant) - Prior Authorization required

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Infusion site of care / Medical oncology & supportive care (Carelon review)HCPCS|CPT|QCovered

C9094	Inj Sutimlimab-Jome 10 mg - code termed 10/01/2022 replaced with J1302
J0219	Avalglucosidase Alfa-Ngpt injection - add effective 04/01/2023
J0223	Givlaari (Givosiran) - Prior Authorization required
J0224	Lumasiran injection - add effective 04/01/2023
J0491	Anifrolumab-Fnia injection - add effective 04/01/2023
J0517	Fasenra (Benralizumab) - Prior Authorization required
J0638	Ilaris (Canakinumab) - Prior Authorization required
J0791	Adakveo (Crizanlizumab) - Prior Authorization required
J1301	Radicava (Edaravone) - Prior Authorization required
J1302	Inj, Sutimlimab-Jome 10 mg - add effective 07/01/2023

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Required Provider Actions & Billing Rules

Prior Authorization

Prior authorization required

Prior authorization is required through BCBSNM for the listed codes and drugs for ASO members. Some oncology/supportive care drugs are delegated to Carelon (formerly AIM) — Carelon will only review requests supported by an oncology diagnosis or when the drug has oncology indications; other requests are reviewed by BCBSNM.

Documentation Required

Delegation / review routing rules

Send PA requests to BCBSNM for provider-administered therapy or infusion site of care. Send PA requests to Carelon for medical oncology and supportive care unless the drug has multiple indications; when multiple indications exist, Carelon will only review oncology-supported requests.

Key Terms

Definitions

CarelonCarelon Medical Benefits Management (formerly AIM Specialty Health) — delegated reviewer for medical oncology & supportive care in many listed items.

ASOAdministrative Services Only members (self-funded/employer groups managed administratively by BCBSNM).

Infusion Site of CareCategory used on the list to indicate drugs administered in an infusion/infusion site setting; may affect reviewer routing.

Carelon review ruleCarelon will review oncology/supportive-care drug requests only when supported by an oncology diagnosis; other requests are reviewed by BCBSNM.

Context and Rationale

This administrative list is intended to manage utilization of specialty infusions and provider‑administered therapies by defining prior authorization requirements and reviewer routing. Items marked as Medical Oncology & Supportive Care are generally reviewed by Carelon (formerly AIM) when requests are supported by an oncology diagnosis; requests for non‑oncology indications or items outside Carelon's delegated scope are reviewed by BCBSNM. The list also documents code terminations and replacements, delegation notes, and reminds providers that prior authorization or eligibility checks do not guarantee payment—the member’s benefits at claim receipt determine coverage.

Document Dates & Changes

Effective: 2023-09-18. Last review: . Next review: .