ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A

Specialty drugs prior authorization list

List of procedure/drug codes that may require prior authorization for medical-benefit specialty pharmacy and infusion services for Blue Cross Blue Shield of Oklahoma members; indicates which manager (BCBSOK or Carelon) handles requests and effective/add/remove notes.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicySpecialty drugs prior authorization list

Policy CodePolicy N/A

Change TypeAdditions and operational updates

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must check eligibility/benefits (e.g., via Availity) to determine if prior authorization is required and send PA requests to BCBSOK or Carelon per the code-specific routing.

SourceLink

POLICY UPDATE CHANGES

Multiple CPT/HCPCS codes (e.g., C9163, C9165, J1576, J9064, J9259, J9286, J9321) were added with an effective date of 04/01/2024 and are to be prior authorized through Carelon for oncology-supported indications.

Several infusion-site codes (e.g., J1302) were added or had effective dates updated (e.g., J1302 Add Effective 07/01/2023).

Code Q2049 (Imported Lipodox Inj) is marked as retired effective 04/01/2024.

100+listed procedure/drug codes (partial document)

Carelon & BCBSOKmanagers handling prior authorizations

04/01/2024multiple additions effective date

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default effective date

Carelonprimary reviewer for many oncology drugs

Prior Authorization Coverage Criteria

Per-code prior authorization management and effective dates

Per-code entries indicate whether prior authorization is required, which organization will review requests (Carelon or BCBSOK), and any effective/add/retire notes.

ALL of the following

ANY of the following
- C9163 — Talvey (talquetamab-tgvs): Managed by Carelon; Add Effective 04/01/2024; Prior authorization required through Carelon.
- C9165 — Elrexfio (elranatamab-bcmm): Managed by Carelon; Add Effective 04/01/2024; Prior authorization required through Carelon.
- J1576 — Panzyga (immune globulin intravenous): Managed by Carelon; Add Effective 04/01/2024; Prior authorization required through Carelon.
- J9064 — Cabazitaxel: Managed by Carelon (see per-code notes).
ALL of the following
- Q2049 — Imported Lipodox Inj: Managed by Carelon; Retire Effective 04/01/2024.
- J1726 — Makena 10 Mg: Provider Administered Drug Therapy; Managed by BCBSOK; Retire Effective 01/01/2024.
- C9094 — Inj Sutimlimab-Jome 10 Mg: Infusion Site of Care; Managed by BCBSOK; Code termed 10/01/2022 (replaced with J1302).
ALL of the following
- Except as otherwise noted in the Update History column, these prior authorization requirements are effective on January 1, 2023.

ALL of the following

Some drugs/codes have multiple indications; Carelon will only review requests that are supported by an oncology diagnosis. Non-oncology indications for the same code will be reviewed by BCBSOK as noted per-code.

ALL of the following

ANY of the following
- C9163, C9165, J1576, J9259, J9286, J9321 — Prior authorization required through Carelon; many entries show Add Effective 04/01/2024.
ANY of the following
- J0129, J0180 and selected infusion-site/provider-administered codes — Prior authorization required through BCBSOK (some added to Small Groups/Mid-Markets on specified dates).

General prior authorization stance

Prior authorization is required for the listed codes; reviewer routing depends on diagnosis and per-code designation.

ALL of the following

Prior authorization is required for the listed codes; request routing depends on reviewer assignment and clinical indication.
Carelon will review requests for drugs when the request is supported by an oncology diagnosis; if the drug requested is not associated with an oncology diagnosis, it will be reviewed by BCBSOK (per-code exceptions and group applicability are noted).
Operational transfers: several prior authorization responsibilities were moved from BCBS to Carelon effective 01/01/2023 for specified codes.

ALL of the following

ANY of the following

Prior authorization coverage criteria (summary)

Summary: provider-administered drug therapy and selected oncology/supportive-care injectables on this list require prior authorization; routing is determined by code designation and clinical diagnosis.

ALL of the following

Prior authorization required: Most listed Q-, J-, C- and related codes require prior authorization as specified in the per-code list.
Reviewer assignment: Carelon will review requests for oncology drugs when supported by an oncology diagnosis; non-oncology requests or codes designated to BCBSOK will be reviewed by BCBSOK. Some codes are marked 'Carelon or BCBSOK' and include instructions to route based on diagnosis.
Effective dates and staged adds: Some codes show staggered add/effective dates (examples: Q5125/Q5126 added 04/01/2023; Q5127 add effective 07/01/2023; Q5130 add effective 07/01/2023). Other codes show adds effective 07/01/2023 and 10/01/2023. Except where noted, default effective date is 01/01/2023.
Payment note: Authorization or eligibility check is not a guarantee of payment; final benefits are determined at claim adjudication per member coverage.

Codes and Effective Dates

Examples of codes and names on the PA listmixedCovered

C9163	Talvey (talquetamab-tgvs) - Medical Oncology & Supportive Care
C9165	Elrexfio (elranatamab-bcmm) - Medical Oncology & Supportive Care
J1576	Panzyga (immune globulin intravenous) - Medical Oncology & Supportive Care
J1302	Inj Sutimlimab-Jome 10 Mg - Infusion Site of Care (added effective 07/01/2023)

Selected C-codes (examples)HCPCSCovered

C9142	Alymsys (Bevacizumab-Maly)
C9146	Elahere (Mirvetuximab Soravtansine-Gynx) - code termed 07/01/2023 replaced with J9063

Selected J-codes (examples)HCPCSCovered

J9311	Inj Rituximab Hyaluronidase
J9380	Inj Teclistamab Cqyv

Selected Q-codes (examples)HCPCSCovered

Q5101	Injection Zarxio
Q5120	Inj Pegfilgrastim-Bmez 0.5Mg

Selected Q-codes (oncology/supportive care)HCPCSCovered

Q4081	Medical Oncology & Supportive Care; Epoetin Alfa 100 Units Esrd
Q5101	Injection Zarxio
Q5105	Inj Retacrit Esrd On Dialysi
Q5110	Nivestym

Selected J-codes (provider-administered drug therapy)HCPCSCovered

J0881	Darbepoetin Alfa Non-Esrd
J0885	Epoetin Alfa Non-Esrd
J9035	Bevacizumab Injection
J9312	Rituximab Injection

High-cost/specialty therapies (gene and CAR-T therapies)mixedCovered

J1411	Hemgenix Per Tx Dose (add effective 01/01/2024)
J3398	Luxturna Injection
Q2041	Axicabtagene Ciloleucel CAR-T

Default effective date01/01/2023 unless Update History indicates otherwise

Applicability noteApplies to prior authorization requirements listed in this document unless a specific code row lists a different add/effective date

Search tipUse the Update History column to confirm if a code has a different effective date

Document-level effective date01/01/2023

Exception handlingCodes with an Update History entry may have staggered add/remove dates (e.g., 04/01/2023, 07/01/2023, 10/01/2023, 01/01/2024)

What Providers Must Do

Prior Authorization

How to submit prior authorization requests

Check member eligibility and benefits before submitting a prior authorization (PA) request. Providers should verify whether a PA is required using Availity® or their preferred vendor and then submit the PA to the designated reviewer (BCBSOK or Carelon) as indicated for the service/drug and diagnosis.

Verify member eligibility and benefit details (e.g., Availity) prior to submission.
Submit PA to the designated reviewer per routing rules below.

Note

Delegation rules between BCBSOK and Carelon

Carelon Medical Benefits Management and BCBSOK share delegated responsibility for PA review. Carelon reviews requests for Medical Oncology & Supportive Care — but only when the drug is supported by an oncology diagnosis. BCBSOK reviews Provider Administered Drug Therapy or Infusion Site of Care requests and any drug requests that are not associated with an oncology diagnosis. When a drug has multiple indications, routing is determined by the diagnosis; refer to the Update History / Prior Authorization Delegation Notes for specifics.

Carelon reviews oncology drugs supported by an oncology diagnosis (Medical Oncology & Supportive Care).

Key Terms and Reviewers

OrganizationCarelon Medical Benefits Management

Primary roleReviews prior authorization requests for medical oncology and supportive care drugs when request is supported by an oncology diagnosis

Routing noteProviders should send PA requests for Medical Oncology & Supportive Care to Carelon unless a drug has multiple indications

OrganizationBlue Cross Blue Shield of Oklahoma (BCBSOK)

Primary roleHandles prior authorization for provider-administered therapy or infusion site of care and reviews non-oncology indications where specified

Provider instructionSend PA requests to BCBSOK for Provider Administered Therapy or Infusion Site of Care

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicySpecialty drugs prior authorization list

Policy CodePolicy N/A

Change TypeAdditions and operational updates

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must check eligibility/benefits (e.g., via Availity) to determine if prior authorization is required and send PA requests to BCBSOK or Carelon per the code-specific routing.

SourceLink

On This Page

J1558, J1559, J1561, J1566, J1572, J1575 — Listed as 'Carelon or BCBSOK' with note that Carelon will review oncology-supported requests; non-oncology requests reviewed by BCBS. (Some codes added to Small Groups/Mid-Markets on 10/01/2023 or other dates).

ALL of the following

Multiple J-/Q-/C- entries moved to Carelon with explicit 'Prior Authorization required through Carelon' and effective dates noted (see per-code list).

Examples of provider-administered drug therapy reviewer assignments:

Carelon-managed provider-administered oncology/supportive care examples: Q5125, Q5126, Q5127, Q5130, J0881, J0885, J1599 — Prior Authorization required through Carelon with listed add/effective dates where shown.
BCBSOK-managed provider-administered therapy examples: 90378, C9257, J0202, J0565, J0567, J0585–J0588 — Prior Authorization required through BCBS as indicated; some codes added to group tiers on specified dates.

How to verifyRefer to the Update History / per-code entries for code-specific effective or retirement dates

BCBSOK reviews provider-administered therapy, infusion site of care, and drugs not associated with an oncology diagnosis.

When a drug has multiple indications, routing depends on the diagnosis; consult Update History for code-level delegation details.

Note

Effective date guidance

These prior authorization requirements are effective January 1, 2023 except where the Update History indicates otherwise.

Prior Authorization

Prior authorization routing and reviewer responsibility

Prior authorization requests will be routed to Carelon or BCBSOK based on the procedure code and associated diagnosis. Carelon will handle requests routed to Medical Oncology & Supportive Care (when an oncology diagnosis supports the drug). BCBSOK will handle Provider Administered Drug Therapy or Infusion Site of Care requests and any non-oncology diagnoses. Check the code-level notes in the policy to confirm which vendor is responsible for a given code and any recent operational transfers.

Routing is determined by diagnosis and procedure code; some codes were operationally transferred from BCBSOK to Carelon effective 01/01/2023 or on other dates noted in Update History.
If uncertain, verify routing in the Update History / Prior Authorization Delegation Notes before submission.

Prior Authorization

Carelon prior authorization requirement

Carelon-required prior authorization applies to the oncology and supportive care drugs listed in this document. Providers must submit PAs to Carelon for those codes (or to BCBSOK when the code is routed to BCBSOK). Refer to code-level entries for additions, replacements, and effective dates.

Submit PA to Carelon for codes explicitly listed as Carelon (Medical Oncology & Supportive Care).
Some codes were added or moved to Carelon on specific dates (see Update History for dates such as 04/01/2023, 07/01/2023, 10/01/2023).

Note

Operational transfers

Several PA responsibilities were operationally transferred from BCBSOK to Carelon effective 01/01/2023 (and on other dates noted). Confirm reviewer assignment for each code in the Update History before submission.

Operational transfers from BCBSOK to Carelon are noted at the code level (e.g., J9032, J9153, J9173 and others).
Review Update History for the exact effective date of any transfer.

Prior Authorization

Carelon prior authorization for oncology/supportive care injectables

For oncology and supportive care injectables listed, submit prior authorization requests through Carelon when the request is supported by an oncology diagnosis. If the drug or procedure code is routed to BCBSOK (Provider Administered Drug Therapy or Infusion Site of Care), submit the PA to BCBSOK.

Examples of Carelon-reviewed items include many J-, C-, and Q-codes for Medical Oncology & Supportive Care listed in this document.
If the code is designated BCBSOK in the list (Provider Administered Drug Therapy), submit to BCBSOK.

Prior Authorization

Routing of prior authorization requests (Carelon vs BCBSOK)

Requests are routed to Carelon when the drug is for Medical Oncology & Supportive Care with an oncology diagnosis; non-oncology requests are routed to BCBSOK. Always verify the diagnosis and code-level routing before submission.

Carelon reviews oncology-supported diagnoses; BCBSOK reviews non-oncology diagnoses and provider-administered therapy.
Refer to code entries for mixed routing (Carelon or BCBSOK) and for codes added on specific dates.

Denial Risk

Authorization is not a guarantee of payment

Checking eligibility and benefits and/or receiving a prior authorization is not a guarantee of payment. Payment will be determined when a claim is received and will depend on the member's eligibility, the terms of the member's certificate of coverage on the date of service, and claim-level review.

Authorization does not ensure coverage — final payment decisions occur at claim adjudication.
If you have questions about coverage or claims, contact the number on the member's ID card.

DesignationReviewer refers to either Carelon or BCBSOK as assigned per-code

Routing ruleCarelon will review requests for oncology drugs that are supported by an oncology diagnosis; non-oncology requests are reviewed by BCBSOK

Per-code overridesIndividual code rows indicate which organization is the reviewer and any add/term dates that affect responsibility

Lifecycle statementCodes on the list may be termed (retired) or replaced with alternate codes on specified dates (e.g., C9146 termed 07/01/2023 and replaced with J9063)

Add/remove examplesSome codes show Add Effective or Code Termed entries (examples in Update History per-code rows)

Operational impactWhen a code is termed or replaced, prior authorization routing and reviewer assignment may change per the Update History entry

Carelon reference (document-specific)Multiple code rows explicitly list Carelon as the reviewer (e.g., C9142, C9146, J0881 entries indicate Carelon review)

Role duplicationCarelon appears in both the Definitions and per-code reviewer columns to indicate delegated prior authorization responsibility for oncology-supported indications

Confirm per-codeVerify reviewer assignment in each code row and Update History for changes to Carelon responsibility

ServiceAvaility (third‑party health information network) provides electronic information exchange services for administrative transactions

RelationshipAvaility provides administrative services to BCBSOK; BCBSOK makes no endorsement or warranty regarding third‑party vendors

Provider useProviders may use Availity to check eligibility and benefits and determine if prior authorization is required