CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2021 Specialty Pharmacy Infusion Site Of Care Benefit Preauthorization Drug List

List of medical-benefit procedure codes (J/C/Q codes and some HCPCS) that require prior authorization for provider-administered therapy and/or infusion site of care and/or are delegated to AIM Specialty Health for medical oncology & supportive care review; includes delegation effective dates and notes about oncology-diagnosis requirement for AIM reviews. This part contains code-to-drug mappings and delegation/PA routing notes effective Oct 11, 2021 and Jan 1, 2021 references.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2021 Specialty Pharmacy Infusion Site Of Care Benefit Preauthorization Drug List

Policy CodePolicy N/A

Change TypeDelegations, additions, reason updates, retired code

Effective DateOct 11, 2021

Next Review Date

Key ActionFor listed procedure codes, send prior authorization requests to AIM Specialty Health if the request is for an oncology-supported diagnosis; send PA to BCBSOK for requests not associated with an oncology diagnosis.

SourceLink

POLICY UPDATE CHANGES

Many oncology drug codes were delegated to AIM Specialty Health for review effective 10/11/2021.

Medical Benefit Specialty Pharmacy prior authorization may require PA through BCBSOK effective Jan 1, 2021 for Fully Insured & ASO members.

Multiple procedure/drug administration codes were added to the 2021 list and marked 'Added to list*' or 'Added effective 01/01/2021'.

Many codes have change in 'Reason for Prior Authorization Requirement' to align with updates in Medical Policy.

J9285 (injection, olaratumab, 10 mg) discontinued and retired effective 10/01/2021.

Prior authorization delegation to AIM clarified for many Provider Administered Drug Therapy codes effective 10/11/2021.

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Policy summary and scope

This BCBSOK 2021 Commercial Specialty Pharmacy prior authorization drug list covers medical‑benefit specialty drugs billed with J-/Q-/C-/HCPCS procedure codes for provider‑administered therapy and infusion site of care; it indicates which codes require prior authorization and notes whether PA review is performed by BCBSOK or delegated to AIM Specialty Health for Medical Oncology & Supportive Care. The document explains that AIM will review requests only when supported by an oncology diagnosis and that many oncology delegations are effective 10/11/2021, while Medical Benefit Specialty Pharmacy prior authorization began for some Fully Insured & ASO members effective 01/01/2021, with additional update and retirement notes for specific codes (e.g., J9285 retired 10/01/2021).

Policy metadata

PayerBlue Cross Blue Shield - Oklahoma

Policy Title2021 Specialty Pharmacy Infusion Site of Care Prior Authorization Drug List

Policy NumberN/A

StatusCURRENT

Effective DateUpdated July 2021; changes effective Oct. 11, 2021; Medical Benefit PA reference Jan. 1, 2021

Last Review2021-07

AIM Delegation Effective2021-10-11

Medical Benefit PA Implementation2021-01-01

Prior authorization requirement and routing logic

Prior Authorization Requirement

PA required for listed procedure codes for specified benefit reviews

ALL of the following

Prior authorization requirement: Prior authorization required through BCBSOK or AIM as specified for each procedure code entry (see code_groups for mapping).
Providers must follow the routing note for each code; presence on list does not guarantee coverage.

Procedure codes and mapping to reviewer / PA routing

Codes listed with C9399 / J3490 / J3590 / J3590 etc. (Immune globulin Cutaquig mapping examples)HCPCS|CPT|J-codes|Q-codes

C9399	Cutaquig (Immune Globulin (Human)-hipp) - Reason: Medical Oncology & Supportive Care; PA routing: send to BCBSOK for provider administered therapy or infusion site of care; AIM reviews oncology-supported requests; Effective 10/11/2021 AIM review for oncology diagnoses.
J0882	Aranesp (Darbepoetin alfa) - ESRD; PA routing notes as above.
J1554	Asceniv (Immune Globulin (Human)-slra) - Medical Oncology & Supportive Care; PA routing notes as above.
J3490	Cutaquig (Immune Globulin (Human)-hipp) - Medical Oncology & Supportive Care; PA routing notes as above.
J3590	Cutaquig (Immune Globulin (Human)-hipp) - Medical Oncology & Supportive Care; PA routing notes as above.

Immune globulin and related infusion codes (Infusion Site of Care / Provider Administered Drug Therapy)J-codes|Q-codes

Q5105	Cutaquig = Retacrit (Epoetin alfa-epbx) - Medical Oncology & Supportive Care; AIM reviews oncology requests effective 10/11/2021.
Q5106	Cutaquig = Retacrit (Epoetin alfa-epbx) - Medical Oncology & Supportive Care; AIM reviews oncology requests effective 10/11/2021.
Q5115	Cutaquig = Truxima (Rituximab-abbs) - Medical Oncology & Supportive Care; AIM reviews oncology requests effective 10/11/2021.
Q5119	Cutaquig = Ruxience (Rituximab-pvvr) - Medical Oncology & Supportive Care; AIM reviews oncology requests effective 10/11/2021.
Q5123	Cutaquig = Riabni (Rituximab-arrx) - Medical Oncology & Supportive Care; AIM reviews oncology requests effective 10/11/2021.
J0881	Aranesp non-ESRD (Darbepoetin alfa) - Provider Administered Drug Therapy; Medical Oncology & Supportive Care; AIM reviews oncology requests effective 10/11/2021.
J0885	Non-ESRD Epogen/Procrit (Epoetin Alfa) - Provider Administered Drug Therapy; Medical Oncology & Supportive Care; AIM reviews oncology requests effective 10/11/2021.
J1459	Injection, immune globulin (Privigen) IV, 500 mg - Infusion Site of Care; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J1555	Cuvitru (Immune Globulin (Human) Subcutaneous) - Infusion Site of Care; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J1556	Bivigam (Injection, immune globulin, 500 mg) - Infusion Site of Care; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.

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Additional immune globulin / oncology agents requiring PA (delegated to AIM or BCBSOK depending on diagnosis)J-codes|Q-codes

J1569	Octagam (Injection, immune globulin, IV, 500 mg) = Gammagard liquid - Infusion Site of Care; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J1572	Octagam = Flebogamma/Flebogamma Dif - Infusion Site of Care; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J1575	Octagam = Hyqvia (Immune globulin/hyaluronidase) - Infusion Site of Care; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J1599	Injection, immune globulin, IV, not otherwise specified, 500 mg - Provider Administered Drug Therapy; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J9035	Avastin (Bevacizumab) - Provider Administered Drug Therapy; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J9311	Rituxan-Hycela (Rituximab Hyaluronidase) - Provider Administered Drug Therapy; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J9312	Rituxan (Rituximab) - Provider Administered Drug Therapy; Medical Oncology & Supportive Care; AIM review effective 10/11/2021.
J0641	Fusilev (Levoleucovorin Calcium) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J0642	Khapzory (Levoleucovorin) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J0896	Reblozyl (Luspatercept-aamt) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.

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Oncology supportive agents and biologics (AIM prior authorization required effective 10/11/2021)J-codes|Q-codes

J2505	Neulasta (Pegfilgrastim) / Onpro Kit - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J2820	Leukine (Sargramostim) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J9037	Blenrep (Belantamab mafodotin-blmf) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J9042	Adcetris (Brentuximab vedotin) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J9055	Erbitux (Cetuximab) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J9119	Libtayo (Cemiplimab-rwlc) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J9144	Darzalex-Faspro (Daratumumab-hyaluronidase-fijh) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J9177	Padcev (Fam-trastuzumab) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.
J9179	Halaven (Eribulin) - Infusion Site of Care; Medical Oncology & Supportive Care; Prior Authorization required through AIM effective 10/11/2021.

Multiple oncology drugs delegated to AIM (J9207 - J9358 and Q2049 - Q5122 etc.)J-codes|Q-codes

J9207	Poteligeo mapping shown / Ixempra - Prior Authorization required through AIM effective 10/11/2021.
J9223	Zepzelca (Lurbinectedin) - Prior Authorization required through AIM effective 10/11/2021.
J9227	Sarclisa (Isatuximab-irfc) - Prior Authorization required through AIM effective 10/11/2021.
J9269	Elzonris (Tagraxofusp-erzs) - Prior Authorization required through AIM effective 10/11/2021.
J9281	Jelmyto (Mitomycin Gel) - Prior Authorization required through AIM effective 10/11/2021.
J9302	Arzerra (Ofatumumab) - Prior Authorization required through AIM effective 10/11/2021.
J9303	Vectibix (Panitumumab) - Prior Authorization required through AIM effective 10/11/2021.
J9309	Polivy (Polatuzumab vedotin-piiq) - Prior Authorization required through AIM effective 10/11/2021.
J9313	Lumoxiti (Moxetumomab pasudotox-tdfk) - Prior Authorization required through AIM effective 10/11/2021.
J9316	Phesgo (Pertuzumab-Trastuzumab-Hyaluronidase) - Prior Authorization required through AIM effective 10/11/2021.

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Provider Administered Drug Therapy codes delegated to AIMJ-codes

J2860	Sylvant (Siltuximab) - Provider Administered Drug Therapy; Prior Authorization delegated to AIM effective 10/11/2021.
J9022	Tecentriq (Atezolizumab) - Medical Oncology & Supportive Care; Prior Authorization routing to AIM noted.

Codes with Prior Authorization required / delegated to AIMmixedCovered

Q5116	Poteligeo_(Mogamulizumab-) - Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization required through AIM
Q5117	Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization required through AIM
Q5118	Zirabev_(Bevacizumab-bvzr) - Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization required through AIM
Q5120	Ziextenzo_(Pegfilgrastim-bmez) - Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization required through AIM
Q5122	Nyvepria_(Pegfilgrastim-apgf) - Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization required through AIM
J2860	Sylvant_(Siltuximab) - Provider Administered Drug Therapy Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization delegated to AIM
J9022	Tecentriq_(Atezolizumab) - Provider Administered Drug Therapy Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization delegated to AIM
J9039	Bavencio_(Avelumab) / Blincyto_(Blinatumomab) - Provider Administered Drug Therapy Medical Oncology & Supportive Care; Effective 10/11/2021, Prior Authorization delegated to AIM
J9043	Jevtana_(Cabazitaxel) - Provider Administered Drug Therapy; Effective 10/11/2021, Prior Authorization delegated to AIM
J9047	Kyprolis (Carfilzomib) - Provider Administered Drug Therapy; Effective 10/11/2021, Prior Authorization delegated to AIM

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What providers must do

Prior Authorization

Send PA to appropriate reviewer (AIM or BCBSOK)

For listed procedure codes, send prior authorization requests to AIM Specialty Health if the request is for an oncology-supported diagnosis (AIM will only review oncology-supported requests). For requests not associated with an oncology diagnosis, send PA to BCBSOK for Provider Administered Therapy or Infusion Site of Care.

AIM will only review oncology-supported requests; delegation effective 10/11/2021.

Documentation Required

Verify member benefits and eligibility

Providers must check eligibility and benefits through Availity or their preferred vendor to determine if a prior authorization is required; presence on this list does not guarantee coverage under the member benefits contract.

Key terms

Definitions

AIMAIM Specialty Health — external reviewer for Medical Oncology & Supportive Care PAs; will only review requests supported by an oncology diagnosis.

PAPrior Authorization — pre-service review required for certain provider-administered drugs and infusion site of care as specified.

Added to list*Procedure codes that required prior authorization prior to 01/01/2021 that were added to this 2021 document.

Document changes and effective dates

10/11/2021delegation / effective dateLatest

Many oncology drug codes were delegated to AIM Specialty Health for review effective 10/11/2021.

01/01/2021implementation / effective date

Medical Benefit Specialty Pharmacy prior authorization may require PA through BCBSOK effective Jan 1, 2021 for Fully Insured & ASO members.

01/01/2021added to list / effective date

Multiple procedure/drug administration codes were added to the 2021 list and marked 'Added to list*' or 'Added effective 01/01/2021'.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2021 Specialty Pharmacy Infusion Site Of Care Benefit Preauthorization Drug List

Policy CodePolicy N/A

Change TypeDelegations, additions, reason updates, retired code

Effective DateOct 11, 2021

Next Review Date

SourceLink

On This Page

Billing Rule

Be aware of effective/delegation dates

Some codes began requiring Medical Benefit Specialty Pharmacy PA through BCBSOK effective Jan 1, 2021 for FI & ASO members; many oncology delegations to AIM are effective 10/11/2021. Follow the routing notes for each code accordingly.

Jan 1, 2021 (Medical Benefit Specialty Pharmacy PA implementation for FI & ASO members)
Oct 11, 2021 (AIM delegation effective date)

Prior Authorization

Prior Authorization through AIM required or delegated

Many listed procedure and drug administration codes require prior authorization effective 10/11/2021 and PA processing is delegated to AIM for numerous codes; providers must obtain PA through AIM for listed codes or check delegation note per code.

See code table groups; many codes (e.g., Q5116, J2860, J9022, J9039, J9043, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860, J2860)
Many oncology codes were delegated to AIM effective 10/11/2021.