Precertification / Prior Authorization required

Prior authorization (Precertification) is required for the listed restricted use drugs (both brand and generic equivalents) and for medical-benefit drugs administered using the specified HCPCS/J/Q codes; submit a precertification request and obtain approval before dispensing or administering these drugs when processed under the medical benefit.

• Both brand name drugs and generic equivalents require Precertification (Prior Approval).
• A precertification (prior authorization) request must be submitted and approved for the listed restricted use drug.

Precertification requires correct HCPCS code use

When requesting precertification or submitting claims, providers must use the appropriate HCPCS, J-, Q-, K-, and S- codes listed in this policy for the drug or supply being requested or billed.

• The policy lists HCPCS/J/Q codes (e.g., J0597, J7170, J3357, Q2055) and device/supply codes (e.g., A9276–A9278, K0553) that must be used for prior authorization and claims.
• Codes that identify pharmacy-processed items (A9276–A9278, J0135 examples) are included to determine processing benefit.

Submit prior authorization with the appropriate HCPCS code

Submit prior authorization using the appropriate HCPCS code for the listed drug or supply when requesting precertification; the policy explicitly lists codes to be used for prior authorization and claim submission.

• The policy states prior authorization is required for drugs using specified HCPCS/J/Q codes and provides a comprehensive code list.
• Both brand and generic equivalents are subject to the same precertification requirements and coding expectations.

Use pharmacy point-of-sale processing for self‑administered supplies when applicable

When drugs or devices are processed through pharmacy point of sale (e.g., CGM supplies A9276–A9278 or other listed items), consult the PDL and use pharmacy billing processes rather than medical-benefit precertification forms.

• A9276–A9278 and other codes are processed through pharmacy point-of-sale systems according to the Department of Human Services.
• Consult the Preferred Drug List to confirm processing benefit and any additional prior authorization requirements.

Use medical prior authorization form and consult PDL

Providers must use the medical drug prior authorization (Precertification) form for drugs processed under the medical benefit; the fillable form is available at the URL provided in the policy.

• Medical drug prior authorization forms: https://www.bcbsnd.com/content/dam/bcbsnd/documents/forms/providers/precertification/outpatient-fillable.pdf
• Consult the Preferred Drug List (PDL) to determine whether a medication is processed through the pharmacy benefit or requires medical-benefit precertification.

Member services and grievance contacts

Direct members to Member Services for language assistance, accessibility support, or to obtain grievance forms; providers may advise members to contact Member Services or the Civil Rights Coordinator for help filing grievances.

• Member Services phone (toll-free): 1-833-777-5779 (TTY: 1-800-366-6888 or 711).
• Grievance forms and filing instructions are available at www.medicaid.bcbsnd.com; Civil Rights Coordinator contact details are listed in the policy.

Precertification required — risk of denial/non-payment

Failure to obtain precertification (prior approval) for listed restricted-use drugs when required may result in denial of coverage or non-payment for the drug when it is subject to the medical benefit or limited dispensing.

• Obtain and document prior authorization approval before administering or billing medical-benefit restricted drugs to avoid claim denials or non-payment.

Coding-based denial risk — use listed HCPCS/J/K/Q/S codes

Claims and precertification requests must include the specific HCPCS/J/K/Q/S code that corresponds to the drug or supply; omission or incorrect coding can cause precertification or claim processing issues and potential denials.

• Use the exact HCPCS/J/Q/K/S code listed for the product (examples: J0597, J7170, A9276, K0553).
• Codes for items that are pharmacy-processed (A9276–A9278, J0135 examples) determine benefit and processing pathway.

Determine site of care and billing based on benefit and administration

Medications that do not require professional administration are considered self‑administered and are typically processed on the pharmacy benefit; determine site-of-care and billing path (office/infusion center vs pharmacy) based on benefit and administration.

• Self‑administered items (e.g., CGM sensors/transmitters/receivers, certain injectable drugs when self-administered) are processed via pharmacy point-of-sale systems per the policy.
• Medical‑benefit administration requires appropriate facility/provider coding (office or infusion center) and precertification when applicable.