Blue Cross Blue Shield - Oklahoma Prior Auth Drug List

Coverage and Prior Authorization Requirements

General PA routing and requirement

Prior authorization required for listed codes when applicable

PA requirement and routing: Prior authorization is required for the listed procedure and drug codes; where indicated for oncology or supportive-care indications, requests must be submitted to AIM Specialty Health for review.

AIM will only review when the request is supported by an oncology diagnosis; requests not associated with an oncology diagnosis will be reviewed by BCBS.

General prior authorization for listed drugs

Covered when prior authorization requirements are met and (when specified) supported by applicable clinical guidelines:

General prior auth requirement: Prior authorization is required for the listed provider‑administered J‑codes (effective 01/01/2022); review may be conducted by AIM Specialty Health or by BCBS as specified for each drug.

Refer to individual code entries for per‑code routing (AIM vs BCBS) and any referenced AIM Clinical Guidelines.

Oncology drug review logic

Oncology‑specific routing logic:

Oncology diagnosis requirement: AIM will review oncology drug prior authorization requests that are supported by an oncology diagnosis; if the requested drug is not associated with an oncology diagnosis, the request will be reviewed by BCBS.

Routing (AIM vs BCBS) may affect authorization outcome and required documentation.

Prior authorization and routing

Covered when prior authorization is obtained through the indicated reviewer (AIM or BCBS) and clinical guideline criteria are met

PA routing and guideline review: Prior authorization is required for the listed provider‑administered specialty drugs; requests for oncology indications that include a supporting oncology diagnosis will be routed to AIM for review under AIM Clinical Guidelines, while requests not associated with an oncology diagnosis will be reviewed by BCBS.

Many entries reference AIM Clinical Guidelines or specific advanced therapy categories; specific per‑drug clinical criteria are contained on individual code lines and in AIM guidance.

Prior authorization and review routing

Coverage and review approach for oncology-associated provider-administered drugs

Authorization routing and guideline review: Many oncology and supportive‑care provider‑administered drugs listed require prior authorization and are routed to AIM for review according to AIM Clinical Guidelines; when an oncology diagnosis is not documented, BCBS will perform the review.

Providers should include documentation supporting an oncology diagnosis when applicable to ensure appropriate AIM routing and guideline‑based review.

The presence of a procedure or drug code on this prior authorization list does not guarantee coverage under a member's benefits contract. Codes and requirements may change during the year. Providers must verify member eligibility and benefits through Availity (or their preferred vendor) to determine whether a prior authorization is required for the specific patient and service.

Requests for drugs that would be reviewed under oncology pathways are delegated to AIM Specialty Health only when the request is supported by an oncology diagnosis. If the submitted request for an oncology drug is not associated with an oncology diagnosis, the request will be routed to BCBS for review and may not meet the oncology‑supported criteria applied by AIM.

This segment of the policy does not list any explicit exclusions. The document focuses on prior authorization requirements and routing rather than enumerating specific excluded diagnoses or services.

When a requested oncology drug is supported by an oncology diagnosis, AIM Specialty Health will review the request under AIM Clinical Guidelines. If the oncology drug request is not associated with an oncology diagnosis, the request will be reviewed by BCBS rather than AIM, which determines the authorization path.

This section emphasizes prior authorization routing and requirement (AIM or BCBS) for listed provider‑administered and infusion drugs. It does not define specific 'not medically necessary' scenarios; instead, authorization determinations depend on documentation, diagnosis support, and guideline‑based review by the designated reviewer.

Procedure and Drug Codes (HCPCS / J‑codes)

Listed procedure/drug codesmixed

C9095	medical infusion code referenced for Kimmtrak (tebentatusp-tebn)
C9142	Alymsys (bevacizumab-maly) medical code
C9399	Medical Infusion / Specialty (Cutaquig, Unituxin, others) multiple policy references
C9098	Carvykti (ciltacabtagene) infusion/autologous code
C9257	Avastin (bevacizumab) intravitreal/infusion code
J0129	Orencia (abatacept)
J0180	agalsidase beta (enzyme-replacement therapy)
J0202	Lemtrada (alemtuzumab)
J0221	Lumizyme (alglucosidase alfa)
J0222	Onpattro (patisiran)

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Covered J‑codes requiring prior authorizationHCPCSCovered

J0221	listed — infusion/site‑of‑care; enzyme‑replacement and other specialty med references
J0222	listed — Onpattro (patisiran) and other infusion/site‑of‑care references
J0223	listed — Givosiran and specialty drug site‑of‑care
J0490	listed — Belimumab specialty medication administration site care
J0517	listed — benralizumab specialty medication administration site care
J0565	listed — bezlotoxumab
J0567	listed — cerliponase alfa
J0585	listed — botulinum toxin / Botox
J0587	listed — rimabotulinumtoxinB (Myobloc)
J0598	listed — C1 esterase inhibitor (Cinryze)

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Listed provider‑administered HCPCS/J codes in this segmentHCPCS

J1575	Hyqvia (immune globulin infusion / human) — listed as medical/provider‑administered
J1599	Immune globulin injection/infusion (nonlyophilized) — listed
J1602	Simponi Aria (golimumab) — specialty drug
J1675	Histrelin acetate infusion — specialty drug
J1726	Makena (hydroxyprogesterone caproate) infusion — specialty drug
J1745	Elaprase (idursulfase) infusion — specialty drug
J1746	Trogarzo (ibalizumab‑ulyk) infusion — specialty drug
J1931	Aldurazyme (laronidase) infusion — specialty drug
J1950	Lupron Depot / leuprolide acetate depot — specialty drug
J2182	Nucala (mepolizumab) infusion — specialty drug

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Sample listed HCPCS/CPT codes (partial)HCPCS

J9177	listed in section — Fam-trastuzumab infusion / deruxtecan-nxkil Specialty Drug (as presented)
J9179	Medical infusion entries (e.g., Holaven/Eribulin) referenced
J9204	Poteligeo (Mogamulizumab-kpkc) Specialty Drug
J9308	Cyramza (Ramucirumab) Specialty Drug
J9348	Danyelza (listed)
J9355	Herceptin (Trastuzumab) infusion
J9356	Herceptin Hylecta (Trastuzumab / hyaluronidase)
J9359	Loncastuximab Tesirine-Tpyl

Cell therapy / CAR-T and liposomal productsCPT

02041	Yescarta (axicabtagene ciloleucel) medical infusion / CAR-T
02042	Kymriah (tisagenlecleucel)
02043	Provenge (Sipuleucel-T)
02049	Doxil (liposomal doxorubicin)
02050	Doxil/lipodox (liposomal doxorubicin)
02053	Tecartus (brexucabtagene)
02054	Tecartus (brexucabtagene) specialty drug

Biosimilars and supportive care agentsHCPCS

05103	Inflectra (infliximab-dyyb)
05105	Retacrit (Epoetin alfa-epbx)
05107	Mvasi (Bevacizumab-awwb)
05112	Ontruzant (Trastuzumab-dttb)
05115	Truxima (Rituximab-abbsl)

What Providers Must Do

Note

Check eligibility / preauthorization is not a guarantee

Providers must check member eligibility and benefits through Availity or their preferred vendor before submitting services. The presence of codes on this list does not guarantee coverage — eligibility, benefit limits, and member certificate terms applicable on the date of service determine payment. If you have questions, contact the number on the member's ID card.

Check eligibility and benefits via Availity or your preferred vendor before billing or submitting a prior authorization request.
Checking eligibility or obtaining a preauthorization is not a guarantee of payment; final benefits are determined at claim adjudication.

Prior Authorization

Prior authorization required — follow per‑code routing

Prior authorization is required for many provider‑administered specialty drugs and J‑codes listed in this document. Some prior authorization requests are routed to AIM Specialty Health (AIM) while others are handled directly by BCBSOK — routing is indicated per code. Follow the authorization routing shown with each code (AIM vs BCBS) when submitting PA requests.

Initial Authorization Routing and Criteria

Initial authorization routing

Initial prior authorization routing and guideline references

Initial authorization: Initial prior authorization requests must be submitted to the reviewer indicated on the per‑code entry (AIM or BCBS); many entries reference AIM Clinical Guidelines for initial approvals.

See per‑code entries for exact routing, effective dates, and the AIM guideline category if applicable.

Step Therapy and Guideline References

Requirement	Details
AIM review for oncology indications	When a listed code is routed to AIM for 'Medical Oncology and Supportive Care' or similar AIM categories, providers must follow AIM Specialty Health review pathways and any AIM step/clinical requirements applicable to the oncology indication.
Effect on authorization	AIM will review requests for oncology drugs only when the request is supported by an oncology diagnosis; follow AIM clinical criteria where indicated by the code entry.

Policy statement	Explanation
AIM will review oncology drug requests supported by an oncology diagnosis	Per code-specific notes, AIM will review requests for oncology drugs that are supported by an oncology diagnosis; if the requested drug is not associated with an oncology diagnosis, the request will be reviewed by BCBS.
Sequence/steps	The document does not specify an explicit step‑therapy sequence prior to AIM review; it directs that AIM reviews oncology‑supported requests before BCBS review where delegation applies.

Reference	Implication for prior authorization
AIM Clinical Guidelines / Advanced therapy categories referenced	Multiple entries reference AIM Clinical Guidelines and advanced therapy categories (for example, immunoglobulin therapy and other advanced therapies), implying that authorization decisions will follow AIM guideline‑based review where indicated, though explicit step therapy algorithms are not provided in this segment.
Provider action	When a code entry references AIM Clinical Guidelines or an advanced therapy category, providers should expect guideline‑based review by AIM and submit documentation consistent with AIM requirements.

Guideline reference	Examples / categories
AIM Clinical Guidelines and specific guideline categories	Entries explicitly reference AIM Clinical Guidelines and named categories such as Gonadotropin‑Releasing Hormone (GnRH) agonists/antagonists and other advanced therapy guideline sets, indicating that AIM guideline criteria will apply to prior authorization determinations for those agents.
Specific examples	Chunk examples include GnRH agonists/antagonists (e.g., leuprolide acetate entries) and other oncology/supportive care agents where review is noted as 'AIM Clinical Guidelines' — providers should follow the AIM guideline category noted on the code line.

Administration Setting and Infusion Site Requirements

Billing Rule

Include intended place of infusion/site‑of‑care in PA — site may require authorization

Place‑of‑service (place of infusion) may require prior authorization; code lines list Infusion Site of Care or Provider Administered Drug Therapy as applicable — include intended site of administration in the PA submission.

If the code line indicates 'Infusion Site of Care' or 'Provider Administered Drug Therapy', document the intended site when requesting authorization.
PA may be required for the place of infusion as indicated on the code line.

Documentation Required

Confirm and document site‑of‑care (infusion center or provider office) on PA

Many drugs list a site‑of‑care designation (Infusion Site of Care or Provider‑Administered Drug Therapy); ensure the PA request reflects the correct administration setting.

Biosimilars and Related Notes

Billing Rule

Infliximab and biosimilars require PA per code line (site‑of‑care/routing noted)

Infliximab and its biosimilars (e.g., Inflectra and related codes) are listed with prior authorization and site‑of‑care notes; authorization routing for these infliximab entries is specified on the code line (typically through BCBS).

Check the infliximab code line (e.g., 05103, 05104) for the required reviewer and site‑of‑care.
No specific biosimilar preference or step sequence is detailed in these chunks—follow the per‑code routing.

Policy Background

This document groups medical‑benefit specialty drugs and infusion/provider‑administered codes that may require prior authorization. It indicates when prior authorization is required through BCBS or delegated to AIM Specialty Health (commonly for oncology and supportive care agents) and highlights site‑of‑care considerations (infusion vs provider‑administered). Providers should use the list to identify codes that may need prior authorization and follow the specified routing and AIM Clinical Guidelines where indicated.

Definitions and Key Terms

AIM (external reviewer)

DefinitionAIM Specialty Health — external reviewer to which BCBSOK delegates prior authorization review for many oncology and supportive care drugs.

RolePer the policy, AIM reviews requests for oncology drugs that are supported by an oncology diagnosis; requests not associated with an oncology diagnosis are reviewed by BCBS.

Effective date notePrior authorization requirements and AIM delegations referenced are effective Jan 1, 2022 (see policy effective date).

AIM Clinical Guidelines

DefinitionAIM Clinical Guidelines — clinical guideline set used to support prior authorization determinations for many specialty medications and site-of-care decisions.

ScopeGuidelines referenced include AIM Clinical Guidelines for immunoglobulin (IVIG/SCIG), oncology/supportive care, ESAs, and other advanced therapy categories noted per code entries.

OpenPayer

2022 Commercial Specialty Pharmacy Prior Authorization Drug List