Currentblue cross blue shield - tennesseePolicy N/A

Provider-Administered Specialty Pharmacy Products

A comprehensive list of provider-administered specialty drugs (HCPCS/Q-codes/J-codes and drug names) that require prior authorization; includes contact/methods to request prior authorization and notes about plan/regulatory exclusions. Does not provide clinical coverage criteria per drug.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyProvider-Administered Specialty Pharmacy Products

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAll listed provider-administered specialty drugs require prior authorization; providers must request prior authorization via phone (1-800-924-7141) or Availity Payer Space Specialty Pharmacy application.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

~700Listed HCPCS/J/Q codes

1Prior authorization method (phone)

1Prior authorization method (Availity Payer Space)

Policy summary

This document is a list of provider‑administered specialty pharmacy products (HCPCS/J/Q codes and drug names) that require prior authorization.

It references the separate Medical Policy Manual and the Provider‑Administered Medical Exclusions Policy / Excluded Provider‑Administered Pharmacy Products List for coverage determinations and plan‑specific variations, and includes contact/methods to request prior authorization (phone and Availity Payer Space Specialty Pharmacy application).

Prior authorization requirement

Prior Authorization Requirement

Provider-administered specialty drugs listed require prior authorization. Providers may request a prior authorization review by one of the following methods:

ALL of the following

Phone request: Call 1-800-924-7141.
Availity Payer Space: Log in to Availity, select the Tennessee region -> 'Payer Space' -> 'Authorization Submission/Review' application -> Select 'Specialty Pharmacy'.
Coverage exclusions and plan variations: Some provider-administered drugs may be excluded from coverage for Commercial and Marketplace members or be subject to additional state and/or federal coverage regulations; refer to the Provider-Administered Medical Exclusions Policy and the Excluded Provider-Administered Pharmacy Products List for exclusions and plan-specific variations.
Inpatient/Outpatient authorization when applicable: Some medications may require an inpatient or outpatient authorization along with a medication authorization; fax inpatient authorization to Commercial Utilization Management at 1-866-558-0789 or call 1-800-924-7141 and follow prompts to Prior Authorization, then select option 9.

The list itself does not contain per‑drug clinical criteria or coverage rules. Clinical coverage determinations for each drug are handled in the separate Medical Policy Manual and the Provider‑Administered Medical Exclusions Policy / Excluded Provider‑Administered Pharmacy Products List; providers should refer to those sources for specific clinical requirements and plan variations.

What providers must do

Prior Authorization

Prior authorization required

All provider-administered specialty drugs listed require prior authorization. Providers must request prior authorization by calling 1-800-924-7141 or by logging in to Availity, selecting the Tennessee region -> Payer Space -> Authorization Submission/Review application -> Specialty Pharmacy.

Phone: 1-800-924-7141
Availity: Log in -> Tennessee region -> Payer Space -> Authorization Submission/Review -> Select 'Specialty Pharmacy'

Documentation Required

Inpatient/outpatient authorization when applicable

If an inpatient stay or outpatient procedure is needed in addition to a medication authorization, providers must fax the inpatient authorization request to Commercial Utilization Management at 1-866-558-0789 or call 1-800-924-7141 and follow prompts to Prior Authorization, then select option 9.

Fax: 1-866-558-0789
Phone: Call 1-800-924-7141 -> Prior Authorization -> select option 9

Documentation Required

Check plan-specific coverage and exclusions

Providers must verify member plan coverage and consult the Provider-Administered Medical Exclusions Policy and the Excluded Provider-Administered Pharmacy Products List, as some provider-administered drugs may be excluded for Commercial and Marketplace members or be subject to state or federal coverage regulations.

Common questions

Quick answers

Which products require prior authorization?All listed provider-administered specialty drugs require prior authorization.

Phone method to request prior authorizationCall 1-800-924-7141.

Online method to request prior authorizationAvaility → Tennessee region → Payer Space → Authorization Submission/Review → Specialty Pharmacy.

Where to check exclusions or plan differencesRefer to Provider-Administered Medical Exclusions Policy and Excluded Provider-Administered Pharmacy Products List; coverage varies by plan.

If inpatient/outpatient authorization is also neededFax to Commercial Utilization Management at 1-866-558-0789 or call 1-800-924-7141 and follow prompts to Prior Authorization, then select option 9.