Medical Drugs Requiring Prior Authorization (medical benefit)
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List of injectable and other medical drugs that require prior authorization through the CareFirst Provider Portal for CareFirst members; applies to providers submitting medical (J/C/Q) drug claims under CareFirst plans.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial authorization requirement
Covered when prior authorization is obtained for the listed medical drugs.
Document provides no drug-specific medical necessity criteria
No explicit exclusions are listed in this document. The policy functions as an administrative prior authorization list and does not identify specific services, diagnoses, patient populations, or drugs that are excluded from coverage.
This document does not define any conditions or services as not medically necessary. It is presented solely as a list of medical drugs requiring prior authorization and does not include clinical denial criteria or non‑coverage determinations.
HCPCS / J / Q / C Codes and Drug Names
| J7193 | AlphaNine SD |
| Q5126 | Alymsys |
| C9257 | Empaveli (listed with other codes) |
| J9035 | Avastin (except eye conditions) |
| J7195 | Benefix (also appears with other drugs) |
| J0585 | Botox |
| J2786 | Cinqair |
| J0589 | Daxxify |
| J3060 | Elelyso |
| C9399 | Empaveli (alternate code listing) |
Provider Actions and Prior Authorization
Prior Authorization Required
Prior authorization required for listed medical drugs. Prior authorization requests for the medications listed below must be completed online through the CareFirst Provider Portal.
- Complete prior authorizations online via the CareFirst Provider Portal.
- Failure to obtain prior authorization may result in denial of coverage.
Provider-Impact Highlight
Provider impact: Submitting accurate drug and code information is essential to avoid delays. Ensure the correct HCPCS/NDC and drug name are entered and supporting clinical documentation is available at the time of submission.
How to Submit
How to submit: Providers may submit a prior authorization online by logging in to the CareFirst Provider Portal and navigating to the Prior Auth/Notifications tab. Training resources are available in the Learning and Engagement Center (Medication Prior Authorization course).
- Use the Prior Auth/Notifications workflow in the Provider Portal.
- Have the HCPCS/Q-code and medication name ready (examples below).
- Contact Provider Services if you need Portal assistance.
Prior Authorization Drug List
Medical drugs requiring prior authorization (effective 2026-01-01). The following is a non‑exhaustive list of HCPCS/Q/C codes and medication names that require prior authorization. CareFirst BlueCross BlueShield Medicare Advantage may add or remove drugs from this list at any time.
- J7193 — AlphaNine SD
- Q5126 — Alymsys
- C9257, J9035 — Avastin (except eye conditions)
- J7195 — Benefix
- J0585 — Botox
- J2786 — Cinqair
- J0589 — Daxxify
- J3060 — Elelyso
- C9399, J7799 — Empaveli
- J3590 — Enspryng
- J7326 — Gel-One
- J7320 — GenVisc 850
- J1447 — Granix
- J9355 — Herceptin
- J9356 — Herceptin Hylecta
- Q5146 — Hercessi
- Q5113 — Herzuma
- J7321 — Hyalgan / Supartz FX / Visco-3
- J7322 — Hymovis
- J7202 — Idelvion
- J1745 — Infliximab / Remicade
- J7213, J7195 — Ixinity
- Q5160 — Jobevne
- J1932, J1930 — Lanreotide Acetate
- J2820 — Leukine
- J0887 — Mircera
- J7327 — Monovisc
- J0587 — Myobloc
- J1442 — Neupogen
- Q5148 — Nypozi
- Q5112 — Ontruzant
- J7324 — Orthovisc
- J1307 — Piasky
- J7194 — Profilnine
- J7203 — Rebinyn
- Q5125 — Releuko
- J3285 — Remodulin
- J9312 — Rituxan
- J9311 — Rituxan Hycela
- J7200 — Rixubis
- J1412 — Roctavian
- J9333 — Rystiggo
- J1299 — Soliris
- J7331 — SynoJoynt
- J7325 — Synvisc / Synvisc One
- J3490 — Tegsedi / Wainua
- J2356 — Tezspire
- J7332 — Triluron
- J7329 — TriVisc
- J1823 — Uplizna
- Q5129 — Vegzelma
- J2357 — Xolair
- Note: This list is subject to change; always verify current requirements in the Provider Portal.
Background
This policy is an administrative list identifying medical drugs that require prior authorization. It does not provide clinical indications, dosing rules, step therapy sequences, or medical necessity criteria for individual drugs; prior authorization requests must be submitted through the CareFirst Provider Portal as described in the portal workflow.
Definitions
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