ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A

Commercial Outpatient Specialty Pharmacy Prior Authorization Codes

Lists procedure/drug codes that require prior authorization for outpatient specialty pharmacy services (provider-administered therapy and infusion site of care) for Blue Cross Blue Shield of Oklahoma members and indicates whether requests are managed by BCBSOK or delegated to Carelon for oncology-supportive care.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCommercial Outpatient Specialty Pharmacy Prior Authorization Codes

Policy CodePolicy N/A

Change TypeCode additions, retirements and routing clarifications

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests to BCBSOK for provider-administered therapy or infusion site of care and to Carelon for oncology/supportive care when the drug is supported by an oncology diagnosis.

SourceLink

POLICY UPDATE CHANGES

Several J- and C- codes were added with effective dates (e.g., added to Infusion Site of Care 04/01/24; C9163 added effective 04/01/2024 and to be replaced 7/1/24).

Carelon will review requests for oncology drugs supported by an oncology diagnosis; non-oncology diagnoses will be reviewed by BCBS.

Multiple codes were designated to require prior authorization through Carelon (e.g., many J9xxx/J90xx entries) effective various dates.

J9286 (Glofitamab-Gxbm) added effective 04/01/2024 and requires prior authorization through Carelon.

J9321 (Epcoritamab-Bysp) added effective 04/01/2024 and requires prior authorization through Carelon.

J9345 (Retifanlimab-Dlwr) added effective 01/01/2024 and requires prior authorization through Carelon.

J9313 (Moxetumomab Pasudotox-Tdfk) is marked to retire effective 04/01/2024.

Q2049 (Imported Lipodox) is marked to retire effective 04/01/2024.

Multiple J-/Q-/Q20xx codes (e.g., J1411, J1412, J1413) added with specified effective dates and require prior authorization through BCBSOK.

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policy effective/updated date

Carelonauthorization delegation for oncology

20+HCPCS/Codes requiring PA

04/01/2024codes added effective

Carelon or BCBSOKrouting entities

Prior Authorization and Routing Rules

Prior Authorization requirements and routing

Prior authorization required for listed codes; management may be delegated to Carelon for oncology-supported uses.

Prior authorization is required for provider-administered drug therapy and/or infusion site of care for the procedure codes listed in this document.

Per the policy, prior authorization confirms medical necessity as defined by the member's benefit plan.

Routing: If the request is for a medical oncology or supportive care drug that is supported by an oncology diagnosis, submit the prior authorization request to Carelon Medical Benefits Management; otherwise submit to BCBSOK.

Carelon will only review oncology drugs supported by an oncology diagnosis; non-oncology diagnoses are reviewed by BCBSOK.

Examples: Certain unclassified codes (e.g., C9399, J3490, J3590, J9035) are managed by Carelon (additions effective 10/01/2024) and require prior authorization through Carelon.

Prior authorization requirement and routing

Administrative coverage routing and prior authorization requirement statements for listed infusion/oncology codes.

Codes listed for infusion site of care or medical oncology & supportive care require prior authorization.

Submit prior authorization to the designated reviewer per code mapping: Carelon for oncology/supportive care codes when supported by an oncology diagnosis; BCBSOK for other provider-administered infusion codes or when the drug is not oncology-associated.

Specific examples include J9312 (Carelon or BCBSOK; added to Infusion Site of Care 04/01/24) and multiple listed Carelon-managed oncology codes (e.g., C9163, J0641).

Provider-administered infusion examples

J0129 — Infusion Site of Care; prior authorization required through BCBSOK.
J0180 — Infusion Site of Care; prior authorization required through BCBSOK.
J0221 — Infusion Site of Care; prior authorization required through BCBSOK.

Prior authorization and effective date criteria

Prior authorization requirement and routing rules for provider-administered drugs in this segment:

Prior authorization is required for the listed HCPCS/J/Q codes for provider-administered drug therapy; the reviewer (Carelon or BCBSOK) is specified per code.

Some entries include effective or retirement dates — providers must note the effective/add or retire dates when submitting requests.

Examples: J1599 and other entries note Carelon review and that Carelon reviews oncology drugs supported by an oncology diagnosis; J1726 is marked retired effective 01/01/2024 in other segments.

Prior authorization requirement for listed codes

Most listed J-, Q-, and other HCPCS codes require prior authorization through BCBSOK; some codes show add or retire effective dates and status notes.

Providers are responsible for requesting prior authorization before performing services for in-network members; decisions are communicated to the provider.

Verify member benefits and prior authorization vendor via Availity or the member ID card prior to submitting.

Representative BCBSOK prior-auth codes (selected)

J1411 — Prior authorization required through BCBSOK (Add effective 01/01/2024).
J1412 — Prior authorization required through BCBSOK (Add effective 04/01/2024; contains nominal 2 x 10^13 vector genomes).
J1413 — Prior authorization required through BCBSOK (Add effective 04/01/2024).

Listed Procedure and Drug Codes

Unclassified drug codesCPT

C9399 / J3490 / J3590 / J9035

Unclassified drugs or biologics; code management delegated to Carelon for oncology-supported indications (additions effective 10/01/24)

Infusion / provider-administered codes (sample)CPTCovered

J0219, J0223, J0224, J0485, J0491, J0517, J1301, J1302, J1303, J1305, J1306, J1823, J1930

Infusion site of care or provider administered drug therapy codes requiring prior authorization through BCBSOK

Provider-administered infusion codes (selected examples)HCPCSCovered

J9312	Infusion Site of Care; Injection Rituximab 10 mg; Carelon or BCBSOK routing; added to Infusion Site of Care 04/01/24
J0129	Infusion Site of Care; Injection Abatacept 10 mg; Prior Authorization required through BCBSOK
J0180	Infusion Site of Care; Injection Agalsidase Beta 1 mg; Prior Authorization required through BCBSOK

Oncology specialty codes migrating to CarelonHCPCSCovered

C9163	Talvey (Talquetamab-Tgvs) — Medical Oncology & Supportive Care; managed by Carelon; add effective 04/01/2024; to be replaced by J3055 7/1/24
J3263	Talquetamab-Tgvs 0.25 mg — mapped/added effective 07/01/2024; Prior Authorization required through Carelon

Selected code examples with status notesHCPCSCovered

J9286	Injection Glofitamab-Gxbm 2.5 Mg
J9313	Injection Moxetumomab Pasudotox-Tdfk 0.01 Mg (retire 04/01/24)
Q2049	Injection Doxorubicin Hydrochloride Liposomal Imported Lipodox 10 Mg (retire 04/01/24)

Provider-administered drug therapy codesHCPCSCovered

J1411	Provider Administered Drug Therapy — injection entries; Prior Authorization required through BCBS (add effective 01/01/2024)
J1412	Provider Administered Drug Therapy — gene therapy product containing nominal 2 x 10^13 vector genomes; Prior Authorization required through BCBS (add effective 04/01/2024)
J1413	Provider Administered Drug Therapy — specified therapeutic dose entries; Prior Authorization required through BCBS (add effective 04/01/2024)
J1428	Provider Administered Drug Therapy — Eteplirsen 10 mg; Prior Authorization required through BCBS
J1562	Provider Administered Drug Therapy — Immune Globulin (Vivaglobin) 100 mg; Prior Authorization required through BCBS
J1726	Provider Administered Drug Therapy — Hydroxyprogesterone caproate (Makena) 10 mg (retired effective 01/01/2024)
J1961	Provider Administered Drug Therapy — Lenacapavir 1 mg; Prior Authorization required through BCBS (add effective 07/01/2024)
J2326	Provider Administered Drug Therapy — Nusinersen 0.1 mg; Prior Authorization required through BCBS
J2562	Provider Administered Drug Therapy — Plerixafor 1 mg; Prior Authorization required through BCBS
J2941	Provider Administered Drug Therapy — Somatropin 1 mg; Prior Authorization required through BCBS

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Vector genome quantities — nominal and maximum values

Nominal vector genomes (example)J3398 lists nominal 1 x 10^9 vector genomes per product/dose.

Maximum vector genomes (example)J3399 specifies up to 5 x 10^15 vector genomes per product/dose.

Topical product vector concentrationJ3401 specifies nominal 5 x 10^9 pfu/mL vector genomes per 0.1 mL for topical administration.

Per-therapeutic-dose specificationSome gene/CAR-T entries (e.g., Q2041, J9029) specify vector or cell quantities per therapeutic dose rather than per mg or unit.

What Providers Must Do

Prior Authorization

Where to send PA requests

Send prior authorization (PA) requests to BCBSOK for provider‑administered therapy or infusion site of care. Send PA requests to Carelon for Medical Oncology & Supportive Care. Carelon will review requests for oncology drugs only when supported by an oncology diagnosis; if the drug requested is not associated with an oncology diagnosis, the request will be reviewed by BCBSOK.

Carelon reviews Medical Oncology & Supportive Care requests and manages C9399, J3490, J3590 unclassified drug/biologic codes (prior authorization required through Carelon).
BCBSOK manages Prior Authorization for provider‑administered drug therapy and infusion site‑of‑care J/Q codes listed in BCBSOK-managed entries.
When a code or drug has mixed routing (Carelon or BCBSOK), Carelon will review if an oncology diagnosis is present; otherwise BCBSOK reviews.

Prior Authorization

PA required codes (examples)

Specific provider‑administered and infusion site of care HCPCS/J/Q codes require prior authorization; some codes are managed by Carelon (Medical Oncology & Supportive Care) and others by BCBSOK (Provider Administered Drug Therapy / Infusion Site of Care). Examples below illustrate routing and notes.

Key Terms and Roles

Carelon — definition

DefinitionCarelon Medical Benefits Management — contracted vendor for Medical Oncology & Supportive Care utilization management for BCBSOK.

RoleReviews prior authorization requests for medical oncology and supportive care drugs when managed by Carelon per delegation notes.

Effective scope noteManages unclassified drug codes (e.g., C9399, J3490, J3590) with specified adds effective 10/01/2024.

PA routing — where to send prior authorization requests

Primary routing ruleSend PA requests for provider-administered therapy or infusion site of care to BCBSOK unless the drug is managed by Carelon per delegation for oncology/supportive care.

Oncology-supported requestsSend PA requests to Carelon for medical oncology and supportive care when the drug is supported by an oncology diagnosis.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCommercial Outpatient Specialty Pharmacy Prior Authorization Codes

Policy CodePolicy N/A

Change TypeCode additions, retirements and routing clarifications

Effective DateJan 1, 2024

Next Review DateN/A

SourceLink

On This Page

J1726 — Prior authorization through BCBSOK (marked Retire effective 01/01/2024).

Selected gene/CAR‑T therapy codes

J3398 — Voretigene neparvovec-rzyl (1 billion vector genomes); prior authorization required through BCBSOK.
J3399 — Onasemnogene abeparvovec-xioi (up to 5 x 10^15 vector genomes); prior authorization required through BCBSOK.
Q2041 / Q2053–Q2056 — CAR‑T and related therapies (prior authorization required through BCBSOK).

Carelon-managed oncology/supportive care examples: J9269, J9271–J9273, J0641–J0642, J0882, J0896 (prior authorization through Carelon).
BCBSOK-managed infusion/provider‑administered examples: J0219, J0223, J0224, J0485, J0491, J0517, J0791, J7183, J9332 (prior authorization through BCBSOK).
Some codes are dual‑managed: J1551, J1554, J1599, 90283–90284, 90378 — Carelon reviews when oncology diagnosis is present; otherwise BCBSOK reviews.

Prior Authorization

Prior authorization routing — BCBSOK / Carelon split review

Routing depends on diagnosis and the drug: Carelon will review prior authorization requests for oncology drugs supported by an oncology diagnosis. Requests for the same drug without an oncology diagnosis — or for provider‑administered therapies and many infusion site codes — are routed to BCBSOK. Refer to specific code entries for final delegation.

If code entry lists Carelon or BCBSOK, follow that assignment; where both are listed, Carelon reviews for oncology diagnoses and BCBSOK reviews non‑oncology indications.
Examples of BCBSOK routing for provider‑administered/gene/CAR‑T therapies: Q2041–Q2056, J1411–J341, and other gene/CAR‑T codes are routed to BCBSOK per their entries.
Always check the code-specific note and effective dates — some codes were added or changed with effective dates (e.g., additions 04/01/2024, 07/01/2024, 10/01/2024).

Note

Provider prior auth process note

Providers are usually responsible for requesting prior authorization before performing a service for in‑network members. Once a PA request is received and processed, the decision is communicated to the provider. Check the member's ID card for the prior authorization phone number or confirm routing/requirements via Availity® or the vendor portal.

This is not an exhaustive list of codes — verify eligibility, benefits, and the correct PA vendor before submitting.
For questions about routing or coverage, call the prior authorization number on the member's ID card or use Availity® Essentials.

Unclassified codes routingUnclassified codes (C9399, J3490, J3590, J9035) are managed by Carelon (adds effective 10/01/2024 noted for some drugs).

Carelon review — operational note

Review policyCarelon will review requests for oncology drugs that are supported by an oncology diagnosis; requests not associated with an oncology diagnosis are reviewed by BCBSOK.

Code assignmentCarelon is designated reviewer for many Medical Oncology & Supportive Care codes (examples: C9163, J0641, J0642, J0882).

Routing exceptionsSome codes indicate 'Carelon or BCBSOK' where review assignment depends on diagnosis or other code notes.

Code effective / replacement note

Add Effective / Replace'Add Effective' marks when a code/entry is added (e.g., C9163 add effective 04/01/2024); 'Replace' indicates planned code replacement (e.g., C9163 to be replaced by J3055 on 07/01/2024).

Use for versioningThese annotations identify temporal routing or reviewer assignment changes tied to effective or replacement dates.

Operational impactProviders should reference effective/replace dates to determine which code and reviewer (Carelon vs BCBSOK) apply on service date.

Carelon — review (reference)

Carelon review (reference)Carelon reviews oncology/supportive care PAs when delegated; see code-level assignments for specifics (some entries show Carelon or BCBSOK).

Contracted servicesCarelon is contracted to perform utilization management for designated oncology/supportive care codes per policy notes.

Delegation timingSome Carelon assignments include effective dates indicating when delegation begins for new codes.

BCBSOK — review (when applicable)

BCBSOK reviewerBCBSOK reviews prior authorization requests for provider-administered therapies and infusion site of care when not delegated to Carelon or when the drug is not oncology-associated.

BCBSOK-managed examplesSeveral infusion/provider-administered codes (e.g., J0129, J0180, J0221) are explicitly assigned to BCBSOK for prior authorization review.

Split-review casesSome codes are routed to Carelon or BCBSOK depending on whether an oncology diagnosis supports the request.

Provider responsibilityProviders should send PAs to BCBSOK when BCBSOK is the designated reviewer and check diagnosis mapping for possible Carelon routing.

Prior authorization — definition and process

DefinitionPrior authorization is required to obtain approval from the payer before services are rendered to confirm medical necessity as defined by the member's health benefit plan.

Provider responsibilityUsually the provider is responsible for requesting prior authorization before performing a service for in-network members.

Decision communicationOnce a prior authorization request is received and processed, the decision is communicated to the provider.

Availity / Carelon roles

Availity roleAvaility provides eligibility and benefit checking services; providers should check eligibility and benefits through Availity Essentials or their preferred web portal before submitting services.

Carelon roleCarelon Medical Benefits Management is contracted by BCBSOK to provide utilization management services for designated oncology/supportive care codes.

Checking guidanceChecking eligibility/benefits and prior authorization status via Availity does not guarantee payment; final determination occurs at claim adjudication.