Commercial Outpatient Specialty Pharmacy Prior Authorization Codes (Effective 1/1/2026)
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A searchable list of procedure (J/Q/9-series) codes for Medical Benefit Specialty Pharmacy that may require prior authorization for BCBSOK commercial members, including delegation notes for Carelon (medical oncology & supportive care) vs BCBSOK reviews.
Multiple procedure codes and their managed-by assignments and effective dates were added with effective dates 1/1/2026 and 7/1/2026.
Delegation for oncology drug prior authorization clarified: Carelon reviews oncology drugs supported by an oncology diagnosis; BCBSOK reviews provider-administered therapy or oncology drugs without oncology diagnosis.
J1562 (Vivaglobin) entry marked for removal effective 4/1/2026.
Coverage, Routing, and Delegation Rules
Delegation criteria
Management assignment determines where the prior authorization medical necessity review is performed.
Removals
Effective date change / removal examples from extract.
Administrative coverage notes
Administrative coverage notes and prior authorization routing
Coverage and routing criteria
Routing and coverage stance for injectable oncology drugs:
Review responsibility rules (excerpt)
Routing and review responsibility for provider-administered drugs (excerpt):
Procedure Codes and Mappings (J/Q/9-series)
Where and How to Submit Prior Authorization Requests
How to use list
This file is a searchable PDF. Press "CTRL" and "F" keys at the same time to bring up the search box. Enter a procedure code or description of the service to quickly locate a code and view prior authorization requirements, including whether prior authorization applies to therapy only (Provider Administered Drug Therapy), to place of infusion (Infusion Site of Care), or to Medical Oncology & Supportive Care (managed by Carelon).
Prior Authorization Routing
Send prior authorization requests to BCBSOK for Provider Administered Therapy or Infusion Site of Care. Send prior authorization requests to Carelon Medical Benefits Management for Medical Oncology & Supportive Care when the drug requested is supported by an oncology diagnosis. Carelon will only review oncology drug requests that have an oncology diagnosis; if the drug requested is not associated with an oncology diagnosis, BCBSOK will review the request. Refer to the Update History / Prior Authorization Delegation Notes for details.
- BCBSOK = Provider Administered Therapy or Infusion Site of Care
- Carelon = Medical Oncology & Supportive Care (only for requests supported by an oncology diagnosis)
- If a drug has multiple indications or is not associated with an oncology diagnosis, route per delegation notes — Carelon may not review non-oncology indications.
Unclassified biologics prior auth
Codes that represent unclassified drugs or biologics (for example J0642, J3490, J9999 and other 'Not Otherwise Classified' or 'Unclassified' HCPCS codes) require prior authorization through Carelon when the request is for Medical Oncology & Supportive Care and is supported by an oncology diagnosis. These unclassified codes are managed by Carelon per the code-specific entries in this file; when an unclassified code maps to a specific branded product and a different HCPCS becomes the appropriate code (per updates), that mapping and effective date are noted in the code entries.
- Examples: J0642, J3490, J9999 — code entries indicate these represent unclassified drugs/biologics and are managed by Carelon
- Prior Authorization required through Carelon for unclassified/Not Otherwise Classified antineoplastic drugs or biologics when reviewed as Medical Oncology & Supportive Care
- See individual code entries for specific drugs and effective dates (some drugs moved to specific J- or Q-codes on later effective dates).
Defined Terms and Code Notes
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