2025 Commercial Outpatient Specialty Pharmacy Prior Authorization Codes (Updated April 2025)
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Governs procedure code-level prior authorization requirements for medical-benefit specialty pharmacy (provider-administered therapy and infusion site of care) for BCBSOK commercial members and delegates (Carelon) effective Jan 1, 2025; affects providers submitting PA requests.
Multiple HCPCS/CPT procedure codes and drug-to-code mappings were added with effective dates throughout 2024–2025 and some codes were added to Infusion Site of Care categories effective 07/01/2025.
Carelon Medical Benefits Management will review medical oncology and supportive care prior authorization requests supported by an oncology diagnosis; BCBSOK reviews non-oncology indications and provider-administered or site-of-care reviews as delegated.
Specific drugs (e.g., Tecentriq Hybreza, Unituxin, Avzivi, multiple biosimilars and new agents) were assigned to specific procedure codes with stated effective dates including future 07/01/2025 additions.
Multiple J-, Q-, and C-codes were added to the Provider Administered Drug Therapy and Medical Oncology & Supportive Care categories effective 01/01/2025 (with some additions effective 04/01/2025).
Carelon will review requests for oncology drugs that are supported by an oncology diagnosis; if not oncology-related, BCBS will review.
Prior authorization required through BCBS or Carelon is specified for many listed codes.
Code J0641 (Levoleucovorin NOS) was retired effective 01/01/2025.
Codes C9169 and C9170 were slated to be added 01/01/2025 but were replaced with J9028 and J9026 respectively.
Multiple J- and Q-codes and specific biologics/therapies were added with effective dates (for example, additions effective 01/01/2025 and 04/01/2025).
Some HCPCS codes are marked for retirement (for example, J9258 and J9259 show 'Retire Effective' notes).
Infusion site-of-care assignments were added on 04/01/24 and removed 10/01/24 for multiple codes.
Coverage and Prior Authorization Criteria
Prior authorization requirement and manager assignment
Codes listed require benefit prior authorization for BCBSOK Fully Insured (FI) and ASO members; management of prior authorization may be delegated to Carelon for oncology-supported indications.
Coverage/authorization summary
Many listed codes are assigned to one or more service categories and have per-code reviewer and prior authorization designations; refer to individual entries for examples and effective dates.
See individual code rows for specific 'Managed By' and 'Prior Authorization required through ...' annotations.
Administrative coverage controls
Administrative controls and operational flags present in the code listings include per-code prior authorization routing, add/retire effective dates, and site-of-care changes.
Per-code prior authorization routing
- Some J- and Q-codes are annotated 'Prior Authorization required through Carelon' (examples shown in Medical Oncology & Supportive Care rows).
Operational implication
Coverage stance and operational criteria (excerpt)
High-level coverage and operational guidance for providers when using this list:
Code Listings and Status
| J9176 | Listed with Carelon; prior auth required |
| J9258 | Paclitaxel protein-bound (Teva) – note: 'Retire Effective' appears |
| J9264 | Paclitaxel protein-bound – prior auth required through Carelon |
| Q2043 | Sipuleucel-T; prior auth required through Carelon |
| 90378 | Respiratory syncytial virus monoclonal antibody; prior auth required through BCBS |
| J1413 | Delandistrogene Moxeparvovec-Rokl / per therapeutic dose (provider-administered drug therapy) |
| J1426 | Casimersen, 10 mg (provider-administered drug therapy) |
| J1427 | Viltolarsen, 10 mg (provider-administered drug therapy) |
| J1428 | Eteplirsen, 10 mg (provider-administered drug therapy) |
| J1429 | Golodirsen, 10 mg (provider-administered drug therapy) |
| J1628 | Guselkumab, 1 mg (provider-administered drug therapy) |
| J1747 | Spesolimab-Sbzo, 1 mg (provider-administered drug therapy) |
| J1961 | Lenacapavir, 1 mg (provider-administered drug therapy) |
| J2267 | Mirikizumab-mrkz (provider-administered drug therapy) |
| J2326 | Nusinersen, 0.1 mg (provider-administered drug therapy) |
Provider Submission, Routing, and Authorization Actions
Route PA requests to BCBSOK or Carelon based on therapy and indication
Send PA requests to BCBSOK for Provider Administered Therapy or Infusion Site of Care. Send PA requests to Carelon for Medical Oncology and 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 drug is not associated with an oncology diagnosis, BCBSOK will review the request.
- Refer to the Update History / Prior Authorization Delegation Notes for details on specific code routing.
Carelon reviews oncology-supported drug requests only
Carelon will only review requests for oncology drugs when the request is supported by an oncology diagnosis; requests for non-oncology indications will be reviewed by BCBSOK.
- If a drug has multiple indications, follow the delegation notes to determine whether Carelon or BCBSOK manages the review.
- Delegation applies to Medical Oncology & Supportive Care categories assigned to Carelon in the code listing.
Submit PA requests to Carelon for Medical Oncology & Supportive Care codes
Prior Authorization is required through Carelon for many Medical Oncology & Supportive Care J-/Q-/J9xxx codes (per-code entries indicate 'Prior Authorization required through Carelon').
Reviewer assignment depends on oncology diagnosis
Carelon will review oncology drug requests when supported by an oncology diagnosis; BCBSOK will review requests not associated with an oncology diagnosis.
- This reviewer assignment is repeated across multiple code entries that list 'Carelon or BCBSOK' and include the note about oncology diagnosis support.
- When in doubt, consult the code-level 'Managed By' field to determine the reviewer.
Per-code PA submissions routed to Carelon where indicated
Many listed J-codes are annotated 'Prior Authorization required through Carelon' in the code listing (examples include J9176, J9177, J9179, J9203).
- Confirm Carelon assignment and prior authorization requirement on the per-code line before submitting.
- Follow Carelon processes for prior authorization submission when the per-code entry indicates Carelon.
Per-code PA submissions routed to BCBSOK where indicated
Several provider-administered codes are annotated 'Prior Authorization required through BCBS' and list BCBSOK as the managing entity (examples: 90378, J0202, J0567, J1413, J1426–J1429, J2326).
- Verify the per-code 'BCBSOK' assignment in the listing and submit PA requests to BCBSOK for those codes.
- Note add/retire effective dates on per-code lines when present.
Provider responsibility: request PA before service when required
Prior authorization is required for some members/services/drugs before services are rendered to confirm medical necessity; usually the provider is responsible for requesting prior authorization before performing a service for in-network care.
- Once a prior authorization request is received and processed, the decision is communicated to the provider.
- If you have questions, call the prior authorization number on the member's ID card; always verify eligibility and benefits via Availity or your preferred portal.
Check per-code PA flags to determine submission routing
Multiple HCPCS J-/Q-/J-like codes in the listing include per-code annotations indicating which entity manages prior authorization (for example, entries marked 'Prior Authorization required through BCBS' or 'Prior Authorization required through Carelon').
- Review each code line for the 'Managed By' and 'Prior Authorization' notes to determine where to submit the request.
- Some codes are listed as 'Carelon or BCBSOK' — check the associated diagnosis and delegation notes to route the PA.
External vendor assignments: Carelon and other BCBS entities may manage PA
For some services/members, prior authorization may be required through other BCBS entities or through Carelon Medical Benefits Management per BCBSOK contract; Availity or the member's ID card should be used to confirm vendor and prior authorization number.
- BCBSOK has contracted with Carelon for utilization management and related services for some members; other Blue plans may also require separate PA processes.
- Always verify which vendor to use for prior authorization on a per-member basis via Availity or the member ID card.
Terms and Vendor Definitions
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