CurrentCareSource GeorgiaPolicy N/A

CPT/HCPCS code coverage and prior authorization statuses (partial table)

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This document lists CPT/HCPCS codes with associated brand names, brief descriptions, and prior authorization or coverage designations; it applies to CareSource Georgia's coverage determinations for the codes shown in these pages. This is part 1 of a longer policy table and covers immunizations, injections, parenteral nutrition, certain CGM supplies, and various drug/procedure codes appearing in chunks 0–19.

Policy Summary

PayerCareSource Georgia

PolicyCPT/HCPCS code coverage and prior authorization statuses (partial table)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionCheck the per‑code table to confirm whether a specific HCPCS/CPT entry requires prior authorization or is routed to the pharmacy benefit before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+distinct CPT/HCPCS codes listed

multipleNo Prior Authorization Required

severalPrior Authorization Required

someNot Covered

partialdocument segment

Coverage and Prior Authorization Criteria (excerpt)

Partial code coverage table (excerpt)

Coverage and prior authorization statuses shown for listed codes in these chunks.

ALL of the following

Examples (one or more):
- 90378 — listed with Prior Authorization Required in this fragment (vaccine/antibody administration mapping).
  See vaccine/antibody administration code entries.
- 90380 — No Prior Authorization Required (RSV/monoclonal antibody seasonal dose mapping).
  RSV monoclonal antibody seasonal dose mapping.
- 90381 — No Prior Authorization Required (RSV/monoclonal antibody seasonal dose mapping).
  RSV monoclonal antibody seasonal dose mapping.
- 90584 — No Prior Authorization Required (rabies vaccine/administration mapping shown as No Prior Authorization Required).
  Vaccine administration entry.
Note: the table includes many CPT/HCPCS vaccine and administration codes with mixed PA designations; users should consult the specific line item for each code.
Entries are shown in the cited chunks (partial table).

ALL of the following

0054A[4], 0064A[4], 0094A[4], 90480 — COVID-19 vaccine administration codes shown as No Prior Authorization Required in these chunks.
See administration code lines in chunk 3.

ALL of the following

90683 — marked Not Covered in this fragment (RSV mRNA LNP vaccine entry).
See chunk 5 for Not Covered annotation.
Multiple 9131x–91317 entries — shown as No Prior Authorization Required for bivalent and related COVID-19 vaccine presentations in this segment.
See chunk 5.

CGM coverage excerpt

CGM-related coverage determinations present in table.

ANY of the following

A4222/A4223 — Supply allowance for adjunctive, non-implanted continuous glucose monitor (CGM); listed as Prior Authorization Required.
Adjunctive CGM supply allowance flagged for PA in chunk 7.
A4239 — Non-adjunctive, non-implanted CGM supply allowance (Freestyle Libre/Dexcom) assigned to Pharmacy Benefit and shown as No Prior Authorization Required (Pharmacy Benefit).
Chunk 7 marks A4239 as Pharmacy Benefit / No PA.
A9276 / A9277 / A9278 — Simplera and related CGM sensors/transmitters/receivers listed as Not Covered in this fragment.
See chunk 7 and chunk 8 for Not Covered annotations.

Operational note: the table differentiates adjunctive vs non-adjunctive CGM supplies and may route some lines to the pharmacy benefit; verify benefit routing when billing.

See chunk 7 (benefit assignments).

PA and benefit designations for listed J-codes (partial)

Per the excerpt, each J-code is paired with a designation indicating prior authorization status or benefit type and a mapping to a specific drug product.

ANY of the following

J0134 / J0136 / J0137 / J0138 — Acetaminophen injection variants shown as No Prior Authorization Required in this fragment (manufacturer-specific mappings noted).
Chunk 18 lists J0134–J0138 as No Prior Authorization Required.
J0139 — mapped to adalimumab (1 mg) and designated as Pharmacy Benefit in this fragment; PA routing may follow pharmacy rules.
Chunk 18 shows J0139 mapped and routed to Pharmacy Benefit.
J0174 / J0177 / J0178 / J0179 — Selected ophthalmologic biologics (e.g., lecanemab/Leqembi, aflibercept/Eylea HD, brolucizumab/Beovu) are indicated as Prior Authorization Required on the listed lines.
Chunk 21 marks these J017x entries as Prior Authorization Required in the mapping.
J0604 — Cinacalcet (Sensipar) mapped for ESRD-on-dialysis use and shown as No Prior Authorization Required in this fragment; other J060x entries vary by PA/pharmacy benefit.
Chunk 36 shows J0604 as No Prior Authorization Required while other J060x lines differ.
J0606 — Etelcalcetide (Parsabiv) listed as Prior Authorization Required in this segment.
Chunk 36 shows J0606 = Prior Authorization Required.

Note: these are exemplar per-code mappings from the partial table; many J-code entries in the full listing have mixed PA and benefit assignments—consult the specific code line for final billing/authorization requirements.

See chunks 18, 21, 36 for per-line examples.

Coverage annotations (prior auth / no prior auth / equivalency)

Coverage-related annotations found in these chunks are limited to prior authorization requirements and therapeutic equivalency notes for J-codes.

ALL of the following

Prior authorization examples:
- J0602 / J0603 — shown with Prior Authorization Required and assigned Pharmacy Benefit in some lines.
  Chunk 36 shows J0602/J0603 PA = Pharmacy Benefit.
- J0606 — listed as Prior Authorization Required (example from the J06xx group).
  Chunk 36 shows J0606 = Prior Authorization Required.
No prior authorization examples:
- J0612 / J0613 / J0652 — explicitly shown as No Prior Authorization Required in these lines.
  Chunk 38 shows J0612/J0613 as No Prior Authorization Required; chunk 41/51 include J0652.
Therapeutic equivalence notes:: Multiple entries (e.g., daptomycin-related lines) specify 'not therapeutically equivalent' relationships among manufacturer-specific products, indicating they should not be treated as interchangeable for PA/coverage decisions.
See chunk 51 and related entries for 'not therapeutically equivalent' annotations.

Operational note: PA and benefit designation can differ even within a J-code family depending on manufacturer/NDC mappings; therapeutic equivalence statements affect substitution and PA decisions.

Based on chunks 36, 38, 51.

Prior authorization‑based coverage criteria (partial)

Coverage stance indicated by prior authorization flags for specialty and gene therapy injections in this segment.

ALL of the following

Gene therapy J-codes (examples: J1411–J1414, J1426–J1430) — listed as Prior Authorization Required in this fragment (gene/specialty therapy entries).
Chunk 64 indicates these J14xx entries are Prior Authorization Required.
Selected specialty injectables and IV iron/ferric products (e.g., J1437, J1439, J1440–J1444 entries) — many lines are marked Prior Authorization Required; some related ferric products show Pharmacy Benefit or other dispositions.
Chunk 65 shows J1437/J1439/J1440-J1444 with PA indications.
Operational note: specialty gene- and cell-therapy entries are consistently flagged for prior authorization in this range—providers should expect PA requirements for these high-cost products.
Chunks 64–65.

Exception note: some closely related small entries (e.g., J1434) are shown No Prior Authorization Required — review each line item for exceptions.

See chunk 64 (J1434 = No Prior Authorization Required).

Partial coverage criteria from excerpt

Coverage stance varies by J-code; entries explicitly label whether prior authorization is required or not and sometimes indicate pharmacy benefit routing.

ALL of the following

J1570–J1576 (Triferic and related mappings) — multiple J157x entries shown as Prior Authorization Required for several Triferic mappings (J1571–J1576).
Chunks 72–73 show J1571–J1576 marked Prior Authorization Required.
J1580–J1596 — mixed routing: many entries are routed to the Pharmacy Benefit and listed as No Prior Authorization Required (Pharmacy Benefit), while some codes (e.g., J1599) are shown as Prior Authorization Required.
Chunk 73 indicates mixed PA/Pharmacy Benefit for J1580–J1596.
Insulin pump-related J-codes (J1811–J1815) — generally require Prior Authorization for insulin intended for pump use; several insulin pump entries are explicitly Prior Authorization Required.
Chunk 83 lists J1811–J1815 with PA required for pump-use insulin.

Operational note: when codes are routed to the Pharmacy Benefit in the table, 'No Prior Authorization Required' often reflects pharmacy processing rules rather than medical PA; confirm benefit routing before submission.

Chunks 72–83.

Per-J-code authorization criteria (excerpt)

Per-code prior authorization stance as listed in these chunks.

ANY of the following

J2184 — Prior Authorization Required (meropenem mapping, manufacturer-specific non-equivalence noted).
Chunk 90 lists J2184 = Prior Authorization Required.
J2185 — No Prior Authorization Required (alternative meropenem mapping shown).
Chunk 90 shows J2185 = No Prior Authorization Required.
J2310 — No Prior Authorization Required (naloxone mapping).
Chunk 95 shows J2310 = No Prior Authorization Required.
J2506 — Prior Authorization Required (pegfilgrastim / related colony-stimulating agent entries shown elsewhere in the table).
Chunk 111/101 indicate pegfilgrastim lines with PA required; chunk 90 references colony-stimulating agents overall.

Note: status varies by J-code and product—these per-code examples are taken directly from the cited chunks; consult the full line item for each HCPCS code before billing.

Chunks 90, 95, 109.

Per-code coverage stance (partial)

Stated coverage stance per J-code in this section is limited to simple PA requirement flags and benefit assignment (e.g., Pharmacy Benefit).

ANY of the following

Range J2786–J2805 — mixed stance per line: some specific J2786/J2787/J2788 entries are No Prior Authorization Required while adjacent codes (e.g., J2790) require Prior Authorization.
Chunk 108 and 109 show mixed PA statuses within this range.
J2941 — marked as Pharmacy Benefit in the listing.
Chunk 111 indicates J2941 = Pharmacy Benefit.
J3590 — unclassified biologics: multiple high‑cost gene/cell therapies recorded under J3590 are generally shown with Prior Authorization Required in many entries; a specific exception is noted for Avastin when used for eye injections (No Prior Authorization Required).
Chunk 125 documents J3590 PA nuance (Avastin eye injections exception).
J7030–J7100 — infusion normal saline/dextrose ESRD fluids are marked No Prior Authorization Required in this segment.
Chunk 127 lists these infusion codes as No Prior Authorization Required.

Operational note: unclassified codes (e.g., J3590) may contain both low‑cost and high‑cost product mappings; PA requirement often depends on the mapped product—verify the product/NDC and line-item notes.

Chunks 125 and 127.

Code-level coverage stances (partial)

Stated coverage stance by HCPCS code in this segment

ANY of the following

J7030 — No Prior Authorization Required (normal saline infusion; ESRD-on-dialysis use noted).
Chunk 127 shows J7030 = No Prior Authorization Required.
J7169 — Andexxa (andexanet alfa) listed with Prior Authorization Required annotation in this fragment.
Chunk 129 indicates J7169 listed with Prior Authorization Required in some lines.
J7311 (and related hyaluronan/implant entries) — Prior Authorization Required for many listed implant/hyaluronan products in this range.
Chunk 136/144 indicate PA for hyaluronan/implant products such as J7311/J7322–J7323.

Note: these code-level stances are excerpts—adjacent or manufacturer‑specific lines may carry different PA instructions or pharmacy benefit routing.

Chunks 127, 129, 136.

HCPCS coverage mappings (partial)

Coverage stance for specific HCPCS J‑codes as listed in this segment.

ANY of the following

Prior Authorization Required: Examples: J7336, J7340, J7342, J7345, J7352, J7353 — these J‑codes are listed as Prior Authorization Required in this segment.
Chunk 144 shows J7336, J7340, J7342/J7345, J7352/J7353 with PA required.
Pharmacy Benefit / No PA: Examples: J7515, J7599, J7601–J7606 — some codes are designated Pharmacy Benefit and/or No Prior Authorization Required per these lines.
Chunks 149 and 144 indicate Pharmacy Benefit / No PA mappings for select entries.
Not Covered: Examples: J7632, J7634, J7638 — certain compounded inhalation solutions and related entries are explicitly marked Not Covered.
Chunk 156 lists J7638 (and related J7632/J7634) as Not Covered.

Operational note: the segment includes explicit 'Not Covered' annotations for some compounded products—these indicate denial/coverage risk for those formulations.

Chunk 156.

Per‑code authorization/coverage nodes (excerpt)

Per‑code coverage/authorization indications present in this segment (examples only; not a complete list):

ANY of the following

Coverage decision: No Prior Authorization Required (entry marked as Pharmacy Benefit in the line).
Chunk 162 shows J8541 annotation.
Coverage decision: Prior Authorization Required for some codes in this antiemetic/related group (status varies by specific line).
Chunk 162–164 show mixed PA within the J86xx range.
Coverage decision: Prior Authorization Required (manufacturer/therapeutic equivalence notes affect PA requirement).
Chunk 168 references J9046 with Prior Authorization Required and therapeutic non-equivalence notes.

Note: these per-code nodes are illustrative; the full table contains many more J-code lines with mixed PA and benefit assignments.

Chunks 162–164.

Stated prior authorization stance for sampled codes

Stated coverage/authorization stance for select codes in this extract:

ANY of the following

Stance: Prior Authorization Required (enfortumab vedotin mapping).
Chunk 180 lists J9249 = Prior Authorization Required.
Stance: No Prior Authorization Required (example meropenem/methotrexate mapping line showing No PA).
Chunk 180 shows J9255 with No Prior Authorization Required in part of the line.
Stance: No Prior Authorization Required (tixagevimab and cilgavimab pre-exposure prophylaxis administration mapping).
Chunk 196 indicates M0220 = No Prior Authorization Required.
Stance: No Prior Authorization Required (home administration mapping noted).
Chunk 196 shows M0221 = No Prior Authorization Required.
Stance: No Prior Authorization Required (tocilizumab infusion for hospitalized COVID-19 patients — first dose).
Chunk 196/199 show M0249 = No Prior Authorization Required.
Stance: No Prior Authorization Required (tocilizumab second dose).
Chunk 199 shows M0250 = No Prior Authorization Required.

Operational reminder: COVID-19–related M-codes in this extract are explicitly shown as not requiring prior authorization; confirm clinical eligibility criteria when scheduling administration.

Chunks 196–199.

Coverage notes for listed injectables

Coverage stance and prior authorization notes for listed injectable products and biosimilars in this section.

ANY of the following

Multiple M- and Q-codes (examples: M0222, M0223, Q0220, Q0222, Q0249) are indicated as No Prior Authorization Required for the monoclonal antibody/admin infusion lines in these chunks.
Chunks 198, 206 show many M/Q codes with No Prior Authorization Required.
Some Q-codes (e.g., Q0139 for ferumoxytol-like entries) are explicitly marked Prior Authorization Required — PA varies by product.
Chunk 206 indicates some Q-codes are PA required (e.g., ferumoxytol references).
Biosimilar Q-code mappings (examples in the Q5100–Q5130 range) show mixed PA statuses: many lines alternate between No Prior Authorization Required and Prior Authorization Required depending on the specific biosimilar and listing.
Chunk 212 documents mixed PA assignments for biosimilar Q-codes.

Operational note: biosimilar and monoclonal antibody entries in the Q-code range should be checked per-code for PA status and benefit routing prior to procurement or billing.

Chunks 198, 206, 212.

Q-code PA mapping fragment

Q-code biosimilar products

ALL of the following

Mapped Q-code examples (PA variation):
- Q5116 / Q5117 — mapped to Trazimera/Kanjinti (biosimilar injectables) with supply fee annotations; PA status varies by line.
  Chunk 216 lists Q5116/Q5117 mapping to Trazimera/Kanjinti.
- Q5119 / Q5120 — Ruxience and Ziextenzo biosimilars are shown with lines alternating between No Prior Authorization Required and Prior Authorization Required.
  Chunks 216–217 show Q5119/Q5120 with mixed PA annotations.
- Q5121–Q5130 — Additional biosimilar mappings (Avsola, Nyvepria, Riabni, Byooviz, Releuko, Stimufend, Cimerli, Vegzelma, Fylnetra) with mixed PA assignments; some lines explicitly show 'No Prior Authorization Required = Prior Authorization Required' indicating variance across listings.
  Chunks 217–218 document mixed PA patterns across Q5121–Q5130.
Rule: each Q-code line in this range maps a Q-code to a biosimilar product and records an explicit PA status or benefit assignment; verify the exact Q-code line when determining authorization needs.
Chunks 216–218.

Provider action: check the specific Q-code line for the biosimilar being administered to determine whether prior authorization is required or whether the item is processed under the pharmacy benefit.

Chunks 216–218.

S-code coverage fragment

Home infusion and supply coverage indicators

ALL of the following

S-code examples (mix of PA statuses):
- S0179 / S0197 — No Prior Authorization Required for selected home infusion/home therapy per‑diem and related services.
  Chunk 231–232 show S0179/S0197 with No Prior Authorization Required.
- S5498 / S5501 / S5502 — Home infusion catheter care/maintenance codes are shown with Prior Authorization Required for many complex/implanted access device service lines.
  Chunk 232–233 show S5498/S5501/S5502 with PA required for complex care codes.
- S5550–S5571 / S5566 — Insulin supply and insulin cartridge/pen codes: many lines are No Prior Authorization Required for cartridges and disposable pens; specific entries (S5566, S5570, S5571) show No PA in this excerpt.
  Chunks 232–234 list insulin supply S-codes and No PA annotations.
- S9325 / S9326 / S9327 / S9328 / S9329 / S9330 / S9331 — Home infusion per‑diem codes for pain, chemotherapy and continuous therapy range between No Prior Authorization Required and Prior Authorization Required depending on intensity/duration (e.g., S9326 and S9330 flagged Prior Authorization Required for continuous services).
  Chunks 234–235 show mixed PA for S93xx series.
Note: each S-code entry includes a short service descriptor and an explicit PA flag in the table—verify the exact S-code and service frequency/duration when assessing authorization requirements.
Chunks 231–235.

Provider reminder: home infusion per‑diem codes often require documentation of clinical necessity and care setting; codes flagged PA will need prior authorization before reimbursement.

Chunks 231–235.

Per-code PA stance (examples)

Per-code authorization stance and brief service descriptor entries

Provider action: for C-series cell therapies and complex home infusion per‑diem codes marked Prior Authorization Required, submit PA with therapy-specific clinical documentation (diagnosis, prior treatments, and plan of care).

Chunk 247 guidance implied by PA flags for high-cost items.

Code-level coverage annotations

Coverage stance for codes in this segment is expressed directly as annotations next to each code (e.g., 'No Prior Authorization Required', 'Prior Authorization Required', 'Not Covered').

Operational reminder: the table is partial — verify full policy table for codes not shown here before assuming No PA or Not Covered status.

Chunks 255–262 and inventory metadata.

Code Tables and Mappings (excerpt)

COVID-19 vaccine administration codesCPTCovered

0054A[4]	Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted administration - Booster
0064A[4]	Moderna Covid-19 Vaccine (Low Dose) administration - Booster
0094A[4]	Moderna Covid-19 Vaccine (Aged 18+) administration - Booster
90480	Immunization administration by intramuscular injection of SARS-CoV-2

RSV vaccine codesCPT

90678	Respiratory syncytial virus vaccine, preF, subunit, bivalent
90679	Respiratory syncytial virus vaccine, preF, recombinant, adjuvanted - marked Not Covered
90683	Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use (some entries marked Not Covered)

CGM device/sensor codesHCPCS

A4239	Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM) - Pharmacy Benefit / No Prior Authorization Required
A9276	Simplera continuous glucose monitor sensor; sensor, invasive, disposable - Not Covered

J013x mappingsHCPCSCovered

J0134	Injection, acetaminophen, 10 mg (mapped to acetaminophen injection - Fresenius Kabi); No Prior Authorization Required
J0136	Injection, acetaminophen, 10 mg (mapped to acetaminophen injection - B. Braun); No Prior Authorization Required
J0137	Injection, acetaminophen, 10 mg (mapped to acetaminophen injection - Hikma); No Prior Authorization Required
J0138	Injection, acetaminophen 10 mg and ibuprofen 3 mg; No Prior Authorization Required
J0139	Injection mapped to adalimumab, 1 mg; designated Pharmacy Benefit

Selected ophthalmologic/neuro biologicsHCPCSCovered

J0174	Injection, lecanemab-irmb, 1 mg (Leqembi); listed as Prior Authorization Required
J0177	Injection, aflibercept HD, 1 mg (Eylea HD); listed as Prior Authorization Required
J0178	Injection, aflibercept, 1 mg; Prior Authorization Required
J0179	Injection, brolucizumab-dbll, 1 mg (Beovu); Prior Authorization Required

ESRD-related medications mapped to J060xHCPCSCovered

J0604	Cinacalcet, oral, 1 mg (Sensipar) for ESRD on dialysis; listed as No Prior Authorization Required in this fragment
J0606	Injection, etelcalcetide, 0.1 mg (Parsabiv); listed as Prior Authorization Required

J06xx group mappings and notesHCPCS

J0601	Injection, daxibotulinumtoxina-lanm mapped to sevelamer carbonate 20 mg (ESRD on dialysis)
J0602	Injection mapped to Sevelamer carbonate powder 20 mg; Prior Authorization Required = Pharmacy Benefit
J0606	Injection, etelcalcetide, 0.1 mg (Parsabiv); Prior Authorization Required

Selected J-code clusters (levothyroxine-related and daptomycin/ESA-related)HCPCS

J0650-J0717 (selected examples)	Multiple levothyroxine sodium J-code mappings (J0650-J0717) with therapeutic equivalence notes (selected examples)
J0872-J0896 (selected examples)	Daptomycin and related ESA mappings; prior authorization statuses vary by code (selected examples)

Selected J‑codes and descriptions (partial)HCPCS

J0896	Luspatercept‑aamt injection (listed alongside daptomycin mappings) with mixed PA indications
J0898	Denosumab injection (entries reference argatroban and daptomycin comparisons)
J1160	Digoxin injection / digoxin immune fab references (listed in this segment)

Gene therapy / specialty J‑codesHCPCSCovered

J1411	Etranacogene dezaparvovec‑drlb (Hemgenix) per therapeutic dose; Prior Authorization Required noted for gene therapy J-codes
J1412	Valoctocogene roxaparvovec (Roctavian) per ml; Prior Authorization Required indicated
J1413	Delandistrogene moxeparvovec (Elevidys) per therapeutic dose; Prior Authorization Required indicated
J1414	Fidanacogene elaparvovec (Beqvez) per therapeutic dose; listed as Prior Authorization Required

Example J157x mappingsHCPCS

J1570	Triferic / ferric pyrophosphate citrate solution mapping and prior auth note
J1571	Related immune globulin mapping; Prior Authorization Required for several J157x entries

Insulin pump J-codesHCPCS

J1811	Fiasp insulin for pump use; Prior Authorization Required
J1812	Fiasp/Lyumjev insulin pump entries; Prior Authorization Required

Sample antimicrobial J-codes and statusesHCPCS

J2021	Zyvox (line entry) — No Prior Authorization Required for some entries
J2184	Meropenem (B. Braun) — Prior Authorization Required indicated
J2185	Merrem (meropenem) — No Prior Authorization Required indicated

Colony-stimulating / biologic agentsHCPCS

J2506	Pegfilgrastim (excludes biosimilar) — Prior Authorization Required indicated
J2507	Pegloticase — Prior Authorization Required indicated

Triamcinolone & related injectablesCPT

J3301-J3315

Triamcinolone acetonide formulations and related injectable ophthalmic/musculoskeletal products (Xipere, Triesence, Zilretta) with mixed PA requirements

Unclassified biologics / gene therapiesCPT

J3590

Unclassified biologic/drug code used for multiple high-cost gene and cell therapies (examples: betibeglogene, elivaldogene, exagamglogene, lovo-cel) with PA required in many entries

Infusion / ESRD fluidsCPT

J7030-J7100

Unclassified infusion codes for normal saline and dextrose solutions used for ESRD/dialysis (examples: normal saline solution infusions) - No Prior Authorization Required

Selected saline/dextrose infusionsHCPCSCovered

J3590	Unclassified code usage examples (magnesium sulfate / potassium chloride entries noted)
J7030	Infusion, normal saline solution, 1000 cc — No Prior Authorization Required
J7042	Infusion, 5% dextrose/normal saline (500 ml = 1 unit) — No Prior Authorization Required
J7060	Infusion, 5% dextrose/water (250 cc) — No Prior Authorization Required

Coagulation factors and reversal agentsHCPCSCovered

J7169	Andexxa (andexanet alfa) — Prior Authorization Required
J7170	Hemlibra (emicizumab) — Prior Authorization Required
J7177	Fibryga / RiaStap / Vonvendi and other factor/fibrinogen products — Prior Authorization Required

Selected J‑codes with PA and mapped productsHCPCSCovered

J7336	Mapped examples (e.g., Qutenza/capsaicin 8% patch) — Prior Authorization Required
J7340	Mapped to Duopa and other enteral suspensions — Prior Authorization Required
J7352	Mapped to Scenesse/Nexobrid and others — Prior Authorization Required

Examples of Not Covered compounded inhalation solutionsHCPCSNot Covered

J7632	Cromolyn sodium inhalation solution, compounded unit — Not Covered
J7634	Budesonide inhalation solution, compounded — Not Covered

Representative J‑codes and drug descriptionsHCPCS

J8541	Dexamethasone (hemady) / antiemetic drug entries (example mapping)
J8560	Etoposide; oral, 50 mg (antineoplastic/antemetic group entries)
J8650	Netupitant 300 mg + palonosetron 0.5 mg (Akynzeo) and other antiemetic entries

Additional oncology injectable J‑codesHCPCS

J9040	Bleomycin sulfate injection; bortezomib 0.1 mg; brentuximab vedotin, 1 mg
J9100	Cytarabine, 100 mg; related oncology injectables
J9218	Leuprolide acetate, per 1 mg (example oncology injectable mapping)

Oncology-related injectable J-codes and mappings (partial)CPT

J9280-J9305 (examples)

Codes mapped to tisotumab vedotin-tftv, tebentafusp-tebn, pemetrexed, pembrolizumab and related agents (examples)

Misc. M-codes for home administration and COVID-19 therapiesHCPCS

M0201-M0250 (examples)

Home vaccine administration and monoclonal antibody infusion/admin codes (COVID-19 related); M0201/M0220–M0250 entries shown with No Prior Authorization Required in many instances

Selected M- and Q-codesmixedCovered

M0222	Bebtelovimab injection (mapped in text); No Prior Authorization Required indicated in entries
M0249	Tocilizumab infusion for hospitalized COVID-19 patients (first dose) — No Prior Authorization Required
M0250	Tocilizumab second dose — No Prior Authorization Required
Q0222	Bebtelovimab 175 mg injection — No Prior Authorization Required
Q0220	Tixagevimab and cilgavimab (Evusheld) for pre-exposure prophylaxis — No Prior Authorization Required

Biosimilar product codesmixedCovered

Q5101	Filgrastim-sndz (Zarxio) injection, 1 mcg — biosimilar mapping
Q5103	Infliximab-dyyb (Inflectra) injection, 10 mg — biosimilar mapping
Q5105	Epoetin alfa-epbx (Retacrit) injection, 100 units (ESRD on dialysis) — biosimilar mapping
Q5112	Trastuzumab-dttb (Ontruzant) injection, 10 mg — biosimilar mapping

Q-code biosimilars (partial)mixed

Q5116	Trazimera / Kanjinti — biosimilar injectable, 10 mg
Q5119	Ruxience (rituximab-pvvr) biosimilar, 10 mg
Q5120	Ziextenzo (pegfilgrastim-bmez) biosimilar, 0.5 mg
Q5121	Avsola (infliximab-axxq) biosimilar, 10 mg
Q5122	Nyvepria — pegfilgrastim-apgf biosimilar, 0.5 mg

Home infusion and insulin supply S-codes (partial)mixedCovered

S5501	Home infusion therapy, catheter care/maintenance, complex — per diem (Prior Authorization Required indicated)
S5502	Home infusion therapy, implanted access device — per diem (Prior Authorization Required indicated)
S5550	Insulin, rapid onset (e.g., lispro/aspart); unit-based supply mapping
S5571	Insulin delivery device, disposable pen (1.5 ml or 3 ml) — No Prior Authorization Required indicated
S9329	Home infusion therapy, chemotherapy infusion — per diem (No Prior Authorization Required indicated for some entries)

example S- home infusion servicesHCPCSCovered

S9353	Home infusion therapy, continuous insulin infusion therapy; per diem
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services and supplies — per diem

example C-/J- injections and biologicsmixedCovered

C9301	Obecabtagene autoleucel, up to 400 million CD19 CAR-positive viable T cells, per therapeutic dose — Prior Authorization Required
J0281	Injection, aminocaproic acid, 1 gram

Selected HCPCS mappingsHCPCS

J9054	Mapped to product NIKTIMVO / BORUZU; injection mapping shown (Prior Authorization Required)
J9161	Mapped to product NIKTIMVO / LYMPHIR 300MCG; injection mapping shown (Prior Authorization Required)
Q5147	Mapped to product NIKTIMVO / PAVBLU; aflibercept-ayyh biosimilar mapping (Prior Authorization Required)

Drug/therapeutic equivalence and benefit mappingsmixed

J0601-J0618	Multiple J06xx codes for oral agents (sevelamer, lanthanum, sucroferric, ferric citrate) with notes indicating No Prior Authorization Required for ESRD on dialysis indications
J3373-J3374	Vancomycin-related codes mapped to various injectable therapeutics; No Prior Authorization Required indicated for some

Cell therapy / advanced productsHCPCSCovered

J3402	Remestemcel-l-rknd (Ryoncil) per therapeutic dose — Prior Authorization Required
J3403	Revakinagene taroretcel-lwey per implant — Prior Authorization Required

Provider Action Highlights and Billing Guidance

Note

Vaccine/antibody codes have mixed PA requirements

Mixed prior authorization statuses are shown for vaccine/antibody administration and product codes — e.g., 90378 is annotated as Prior Authorization Required while 90380, 90381, 90584, 90675 and 91304 are listed as No Prior Authorization Required in the table; confirm PA before billing these codes.

Check PA for 90378 (Prior Authorization Required) before submitting.
90380, 90381, 90584, 90675, 91304 are indicated No Prior Authorization Required in this fragment.

Billing Rule

CGM supplies — A4222 requires PA; others use pharmacy benefit or are Not Covered

Adjunctive vs non-adjunctive CGM supplies carry different benefit and PA handling. A4222 (adjunctive CGM supply allowance) is marked Prior Authorization Required; A4239 is assigned to the Pharmacy Benefit and noted as No Prior Authorization Required; A9276–A9278 are listed Not Covered.

Obtain prior authorization for A4222 (adjunctive non-implanted CGM supplies).
Bill A4239 under the pharmacy benefit (no prior auth per table).
Do not bill A9276–A9278 (marked Not Covered).

Prior Authorization

High-cost injectables and radiotherapeutics require prior authorization

Multiple high-cost injectables and radiotherapeutics in the listing are designated Prior Authorization Required; obtain PA before administration/billing for these products.

Examples annotated Prior Authorization Required include A9513/A9606, A9615, C9088–C9092/C9143–C9173 entries.
Refer to per-code lines in chunks 11–13 for radiotherapeutic and high-cost injectable PA designations.

Billing Rule

Selected J013x: most are No PA; J0139 mapped to Pharmacy Benefit

Several J013x entries are documented as No Prior Authorization Required; J0139 is routed to the Pharmacy Benefit. Verify per-line status before claim submission.

J0134, J0136, J0137, J0138 — listed as No Prior Authorization Required in the table.
J0139 is designated 'Pharmacy Benefit' in adjacent mappings; bill via pharmacy benefit if applicable.

Prior Authorization

J017x–J0180 entries now show Prior Authorization Required

Ophthalmologic/neuro J017x–J0180 codes have changed to Prior Authorization Required in the table (example: J0174 for lecanemab/Leqembi is flagged Prior Authorization Required). Confirm PA for these codes prior to service.

J0174 (lecanemab/Leqembi) — Prior Authorization Required.
Several adjacent J0177–J0180 entries also transition to Prior Authorization Required; check each J-code's line-level annotation.

Billing Rule

J060x series — mixed PA and pharmacy benefit assignments; confirm per-code

J060x entries show mixed PA and benefit designations: some lines indicate Prior Authorization Required or Pharmacy Benefit while others (e.g., J0604) are listed No Prior Authorization Required for ESRD oral mappings. Verify per-code benefit and PA before billing.

J0602/J0603/J0605/J0607 are shown with Pharmacy Benefit or Prior Authorization Required annotations.
J0604 (cinacalcet/Sensipar) is shown as No Prior Authorization Required in one fragment — confirm ESRD indication mapping when billing.

Billing Rule

Per-code prior authorization indicators vary (example: J0602, J0606)

Per-code examples illustrate varying prior authorization indicators across J-codes (e.g., J0602 annotated 'Prior Authorization Required = Pharmacy Benefit', J0606 'Prior Authorization Required'). Check each listed J-code's annotation prior to submission.

Use the table entry for the exact PA/benefit mapping (some codes marked 'Prior Authorization Required = Pharmacy Benefit').
Do not assume uniform PA across the J060x range; follow per-code notes.

Billing Rule

Multiple J-codes are listed No Prior Authorization Required — confirm line-level status

Many J-codes are explicitly listed as No Prior Authorization Required; examples in the table include J0612, J0613, J0630/J0636 group entries and several others — verify the line before requesting PA.

J0612 and J0613 — listed No Prior Authorization Required.
J0630/J0636/J0637/J0638 — entries annotated No Prior Authorization Required in this fragment.

Prior Authorization

Per-J-code PA statuses — some J-codes changed PA status (e.g., J0896/J0898)

This segment shows per-code PA designations where some J-codes are annotated as Prior Authorization Required and others No Prior Authorization Required (examples: J0896/J0898 entries show PA changes). Verify each J-code's PA flag.

J0896 and J0898 have line-level PA annotations (table shows changes).
Always reference the code-specific row for current PA status before billing.

Prior Authorization

Gene therapy/specialty J-codes are Prior Authorization Required

Gene therapy and specialty J-codes (e.g., J1411–J1414, J1426–J1430) are explicitly marked Prior Authorization Required in the table; obtain authorization for these high-cost specialty therapies.

J1413/J1414 and J1426–J1429 examples are annotated Prior Authorization Required.
Treat all gene therapy J-codes as requiring prior authorization unless the line indicates otherwise.

Prior Authorization

J157x entries (Triferic) require prior authorization

Multiple J157x lines (Triferic and related mappings) are annotated Prior Authorization Required; J1571–J1576 entries indicate PA is required per table.

J1571–J1576 — Prior Authorization Required for Triferic and mapped immune globulin products.
Follow the per-code PA requirement when billing Triferic-related injections.

Billing Rule

J1580–J1599: mixed PA and pharmacy benefit assignments

Entries for J1580–J1599 show mixed handling: some lines are routed to the Pharmacy Benefit with No Prior Authorization Required, while others (e.g., J1599) are Prior Authorization Required — verify the code-level annotation.

J1580–J1595 lines are shown with Pharmacy Benefit/No Prior Authorization Required annotations.
J1599 and select entries remain Prior Authorization Required; check each row before billing.

Prior Authorization

Insulin-for-pump and certain biologic J-codes require PA

Insulin products for pump use (e.g., J1811–J1814 Fiasp/Lyumjev) and certain biologics (inebilizumab entries) are marked Prior Authorization Required for pump use and biologic administration; secure PA when indicated.

J1811–J1814 annotated Prior Authorization Required for insulin pump administration (Fiasp, Lyumjev).
Inebilizumab (J1823 etc.) is listed with Prior Authorization Required annotations.

Documentation Required

Labetalol and related entries — mixed PA and equivalence notes

Labetalol-related J-code entries show mixed PA annotations and therapeutic nonequivalence notes; follow the table per-code (some labetalol entries are No Prior Authorization Required while others are Prior Authorization Required).

Review therapeutic equivalence notes — some manufacturer-specific labetalol listings are 'not therapeutically equivalent'.
Confirm PA status per exact J-code before billing labetalol/formulation entries.

Billing Rule

Sample J-code PA statuses — verify per-line before billing

The table provides many sampled J-code PA statuses (examples: J2021 No Prior Authorization Required; J2184 Prior Authorization Required; J2185 No Prior Authorization Required). Always confirm the code's line-level PA flag before claim submission.

J2021 marked No Prior Authorization Required in the excerpt.
J2184 is annotated Prior Authorization Required; J2185 annotated No Prior Authorization Required.

Billing Rule

Additional J-codes (e.g., J2310) may be No PA — confirm each code

Additional J-code entries show mixed PA assignments — e.g., naloxone J2310 is listed No Prior Authorization Required; other adjacent J-codes may require PA. Use the table to confirm each code.

J2310 (naloxone) — No Prior Authorization Required per table.
Check neighboring J2311–J2329 for per-code PA differences before billing.

Prior Authorization

Late-chunk J-code entries show mixed PA flags — consult per-code rows

Later J-code entries continue to mix Prior Authorization Required and No Prior Authorization Required flags (examples in J2786–J2800 block); consult the per-code listing for exact PA requirements.

J2788, J2791, J2792 noted No Prior Authorization Required; J2790 and J2797–J2799 show Prior Authorization Required in the fragment.
Follow the per-code table rows for final PA decision.

Prior Authorization

Per-J-code PA statuses (examples include J2788, J2790, J2802)

Per-J-code PA listings include explicit flags such as J2788 No Prior Authorization Required and J2790 Prior Authorization Required; follow the table entry for the exact PA designation when billing.

J2788 — No Prior Authorization Required (Rho D minidose example).
J2790 — Prior Authorization Required (full-dose Rho D immune globulin).
J2802 — Prior Authorization Required (romiplostim/Nplate).

Prior Authorization

J3590 (unclassified biologics) — PA varies by use; gene/cell therapies usually require PA

Unclassified biologic code J3590 is used for many high-cost gene/cell therapies and shows PA nuance: while many J3590 usages are Prior Authorization Required, specific uses (e.g., Avastin when billed as J3590 for eye injections) are listed No Prior Authorization Required. Confirm intended use before billing.

Treat J3590 entries for gene/cell therapies as likely requiring prior authorization unless the line explicitly indicates No Prior Authorization Required (e.g., Avastin for eye injections).
Document the clinical use to justify the J3590 billing and PA status.

Billing Rule

ESRD/infusion fluids (J7030–J7100 etc.) — No PA required

Infusion/ESRD-related unclassified codes for normal saline/dextrose solutions (J7030–J7100, J7042, J7060, J7070) are marked No Prior Authorization Required; these ESRD/infusion fluids may be billed without PA per the table.

J7030, J7040, J7042, J7060, J7070, J7100 — No Prior Authorization Required for listed saline/dextrose infusion products.
Use ESRD-on-dialysis indication mappings shown in the table when billing these infusions.

Billing Rule

Multiple codes are explicitly No Prior Authorization Required — use table to confirm

Numerous HCPCS entries in this segment are explicitly labeled No Prior Authorization Required (examples: J7030, J7040, J7042, J7060, J7070, J7165, J0601–J0608, J0615, 90382, 91323). Confirm the list before seeking PA.

Reference the table rows for exact code lists of No Prior Authorization Required.
Do not submit unnecessary PAs for codes explicitly marked No Prior Authorization Required.

Prior Authorization

Coagulation factors and reversal agents require prior authorization

Many coagulation factor and reversal agent codes (examples: J7169 Andexxa, J7170 Hemlibra and other factor products) are marked Prior Authorization Required in the listing; secure PA for these high-cost hematologic agents.

J7169 (Andexxa) — Prior Authorization Required per table.
J7170 (Hemlibra) and numerous factor VIII/IX/fibrinogen products — Prior Authorization Required.

Billing Rule

Pharmacy benefit mappings — certain codes handled under pharmacy benefit with PA implications

Some entries are assigned to the Pharmacy Benefit or are annotated 'Prior Authorization Required = Pharmacy Benefit' (examples: portions of the Q- and J- code lists and contraceptive device entries). Confirm benefit routing and PA process for those codes.

Codes annotated 'Pharmacy Benefit' may require processing via the pharmacy benefit and may have different PA rules (e.g., J7294–J7307, Q5139–Q5144).
Follow the pharmacy benefit PA workflow where indicated.

Prior Authorization

Hyaluronan/implant products require prior authorization

Various hyaluronan/implant and ophthalmic/orthopedic injectable product codes (J7311–J7336, J7340–J7345, J7320–J7326 range) are marked Prior Authorization Required; obtain PA prior to administration for these implants/injectables.

Examples: J7316–J7326, J7336, J7340, J7342–J7345 — Prior Authorization Required.
Confirm the specific J-code's PA flag when scheduling procedures involving hyaluronan or implant products.

Denial Risk

Not Covered entries present — billing these codes poses coverage/denial risk

Several codes and code ranges are annotated Not Covered (examples include compounded inhalation solutions J7632, J7634, J7638 and related entries); billing these codes risks denial.

J7632, J7634, J7638 and similar compounded inhalation solution entries are marked Not Covered.
Avoid billing or seek prior authorization/medical review only if there is documented exception and payer guidance.

Billing Rule

COVID-19 monoclonal antibody and tocilizumab M-codes — No PA required per table

COVID-19 monoclonal antibody administration and tocilizumab infusion M-codes (M0220–M0223, M0249–M0250) are documented as No Prior Authorization Required for listed indications (pre-exposure prophylaxis and hospitalized COVID-19 infusion); bill per table without PA for these M-codes.

M0220/M0221 (tixagevimab/cilgavimab) — No Prior Authorization Required for listed pre-exposure prophylaxis indications.
M0222–M0223 (bebtelovimab) and M0249–M0250 (tocilizumab for hospitalized COVID-19) — No Prior Authorization Required as annotated.

Billing Rule

Q-code MAb and biosimilar PA status is mixed — confirm per-code

Q-code monoclonal antibody and biosimilar entries have mixed PA annotations: many Q-codes (e.g., Q0222, Q0249, Q5116–Q5120 range) are listed No Prior Authorization Required while others (e.g., Q0139, select Q5xxx entries) are Prior Authorization Required; verify the Q-code row before billing.

Q0222/Q0249 and several Q51xx–Q512x biosimilar lines are annotated No Prior Authorization Required in the excerpt.
Some Q-codes (e.g., Q0139/ferumoxytol-like entries and Q5147–Q5149) are marked Prior Authorization Required — check per-line.

Billing Rule

Q-code biosimilars — PA mappings vary by product and line

Q-code biosimilar mappings show per-line PA changes (examples: Q5119, Q5120, Q5121 etc. show 'No Prior Authorization Required = Prior Authorization Required' toggles). Always use the table row for the final PA designation and map product to code exactly.

Q5119/Q5120/Q5121 and adjacent biosimilar Q-codes show line-level PA variance; verify the product-to-code mapping and PA flag.
Do not assume biosimilars have the same PA handling as innovator products — follow the table.

Billing Rule

S‑codes (home infusion/insulin supplies) — mixed PA; verify per-code

Home infusion and S‑codes (S0197, S5501, S5502, S5517, S5550–S5571, S9325–S9331, S9345–S9353 etc.) include explicit PA designations; some are No Prior Authorization Required (insulin cartridges, certain per-diem codes) while others (continuous/complex home infusion per‑diem codes) require PA — confirm per S-code before billing.

S5550–S5566 and S5571 insulin supply/cartridge/pen codes often No Prior Authorization Required.
S9326, S9330, S9331, S9345, S9346, S9347, S9348, S9336 etc. are marked Prior Authorization Required; obtain PA for continuous/complex home infusion services.

Prior Authorization

Selected J-/C- drug and biologic codes are Prior Authorization Required

Multiple J- and C- drug/biologic codes are annotated Prior Authorization Required in this segment (examples: C9301–C9304 and J9054/J9161 and other high-cost injectables); secure PA for these therapies before administration.

C9301–C9304 (cell and advanced therapy codes) — Prior Authorization Required.
J9054, J9161 and Q5147–Q5149 — annotated Prior Authorization Required; follow per-line PA process.

Prior Authorization

Numerous HCPCS lines are annotated 'Prior Authorization Required' — obtain PA

The table includes explicit 'Prior Authorization Required' annotations for many HCPCS lines (examples: J9054, J9161, Q5147–Q5152, Q9999, Q2057); check and obtain PA where shown.

Refer to the specific HCPCS rows annotated 'Prior Authorization Required' when preparing PA requests.
Do not bill without PA for codes explicitly marked Prior Authorization Required.

Billing Rule

Explicit No Prior Authorization Required entries present — follow table

Several entries in this fragment are explicitly marked No Prior Authorization Required (examples include J0601–J0608, J0615, 90382, 91323); do not request PA for these codes unless clinical circumstances require prior review.

J0601–J0608 and J0615 — No Prior Authorization Required per the table.
90382 and 91323 also annotated No Prior Authorization Required.

Denial Risk

Q0224 marked Not Covered — coverage risk

Q0224 is explicitly marked Not Covered in the listing; billing this code risks denial and it should not be submitted for payment under the listed benefit.

Do not bill Q0224 — marked Not Covered in the table.
If clinically necessary, request medical policy review prior to billing for potential exception.

Note

Status Keywords and Definitions

inv-97: No Prior Authorization Required

DefinitionCode may be billed without obtaining prior authorization as indicated in the table entries.

Typical annotationDisplayed in HCPCS/CPT tables as 'No Prior Authorization Required' next to specific codes (examples: 90380, 90381, 90584, 90480).

Implication for billingProviders may submit claims for listed codes without first requesting PA from CareSource Georgia when the line lists No Prior Authorization Required.

inv-98: Prior Authorization Required

DefinitionCode requires prior authorization before coverage or payment, as indicated in the table entries.

Typical annotationDisplayed in HCPCS/CPT tables as 'Prior Authorization Required' next to specific codes (examples: many J‑codes and select high‑cost injectables such as J2802, J7169).

Implication for providersClaims for these codes may be denied or delayed unless an approved PA is obtained per the payer's process.

inv-99: Not Covered

DefinitionThe code or product is listed as Not Covered in the table and is not payable under the policy.

Typical annotationMarked explicitly as 'Not Covered' for specific formulations or compounded products (examples: 90679 RSV recombinant vaccine; J7638 and other compounded inhalation solutions).

Implication for claimsClaims submitted for items marked Not Covered will not be paid; alternative clinically appropriate options should be considered.

inv-100: No Prior Authorization Required

DefinitionIndicates the listed J‑code/drug does not require prior authorization per this fragment.

Example entriesMultiple J013x lines (J0134–J0139) are shown as No Prior Authorization Required in the table excerpt.

Provider actionNo PA submission is needed for those specific J‑code uses when billed as shown in the mapping.

inv-101: Pharmacy Benefit

DefinitionIndicates the product is administered under the pharmacy benefit rather than the medical benefit for the listed code.

Example mappingSome J06xx and J75xx entries are annotated 'Pharmacy Benefit' (e.g., J0602 = Pharmacy Benefit; J7515 marked Pharmacy Benefit).

ImplicationManagement, PA rules, or coverage routing may follow pharmacy‑benefit processes rather than medical prior authorization workflows.

inv-102: Not therapeutically equivalent

DefinitionManufacturer-specific injectable products are noted as not therapeutically equivalent to other J‑code entries and should not be treated as interchangeable.

Example noteMultiple entries state 'not therapeutically equivalent' for manufacturer variants (e.g., daptomycin Baxter entries flagged vs other J‑codes).

Clinical implicationSubstitution between listed manufacturer products may affect PA requirement or coverage; follow specified mapping in the table.

inv-103: Pharmacy Benefit

DefinitionPharmacy Benefit designation indicating the J‑code/product is handled under pharmacy rules or benefit administration.

ExampleEntries such as J0602 and J7515 are annotated as Pharmacy Benefit in the table excerpts.

NotePharmacy Benefit mapping may change the applicable PA pathway and claim routing.

inv-104: not therapeutically equivalent

DefinitionStatement that certain manufacturer's product entries are 'not therapeutically equivalent' to other J‑codes, used to prevent substitution as equivalent.

ExampleEntries for levothyroxine and daptomycin variants repeatedly note 'not therapeutically equivalent' across manufacturer mappings.

Operational impactUse the exact mapped J‑code/manufacturer entry for authorization and billing decisions rather than assuming interchangeability.

inv-105: Prior Authorization Required / No Prior Authorization Required

DefinitionFlag indicating whether prior authorization is required or not for the listed product (table shows 'Prior Authorization Required' or 'No Prior Authorization Required').

How it's shownEach HCPCS/CPT line entry pairs the code with a short PA designation (examples throughout J‑code and Q‑code lists).

Actionable outcomeCheck the per‑line PA designation before billing; where 'Prior Authorization Required' is shown, obtain PA to avoid claim denial.

inv-106: Not therapeutically equivalent

DefinitionTable notes that certain manufacturer's product entries are not therapeutically equivalent to other J‑codes (explicit non‑equivalence alerts).

ExamplesDaptomycin (Baxter) entries and other manufacturer‑specific listings are repeatedly annotated as 'not therapeutically equivalent' in the excerpt.

ImplicationNon‑equivalence annotations affect substitution, PA evaluation, and coverage—use specified manufacturer mapping for determinations.

inv-107: Prior Authorization Required

DefinitionSimple status label indicating the code requires prior authorization before coverage/payment.

Common useApplied to many gene therapy, specialty and implant J‑codes in the table (e.g., J1411–J1414 and many J73xx entries).

Provider reminderObtain PA per payer instructions for any code line labeled 'Prior Authorization Required'.

inv-108: No Prior Authorization Required

DefinitionNo PA required designation for items handled under the Pharmacy Benefit or explicitly marked 'No Prior Authorization Required'.

ExamplesCertain pharmacy‑benefit mapped entries (e.g., J7515 and many J06xx ESRD oral agent mappings) are annotated as No Prior Authorization Required.

Billing effectWhen listed as No Prior Authorization Required (Pharmacy Benefit), claims may be processed without medical PA but follow pharmacy program rules.

inv-109: J-code prior authorization table

DefinitionTable format pairing HCPCS J‑codes with drug descriptions and a short prior authorization designation (e.g., 'No Prior Authorization Required' or 'Prior Authorization Required').

PurposeProvides per‑code guidance for PA need and maps each code to a product/brand and brief descriptor.

UseRefer to the specific J‑code line in the table for exact PA and product mapping when preparing authorizations or claims.

inv-110: J3590

DefinitionUnclassified code used for products not assigned a specific HCPCS J‑code (J3590).

PA nuanceJ3590 entries include high‑cost gene/cell therapies that are often listed as Prior Authorization Required, while some specific uses (e.g., Avastin for eye injections) are noted No PA Required.

Billing cautionWhen J3590 is used, verify the specific product and PA designation in the payer table to determine coverage and authorization needs.

inv-111: J7030-J7100

DefinitionRange of unclassified infusion codes (J7030–J7100) used for ESRD/dialysis fluids (normal saline/dextrose) and related infusions.

PA statusThese infusion/ESRD fluid codes are shown as No Prior Authorization Required in the excerpt (examples: J7030, J7042, J7060).

Usage noteUsed for billing common dialysis/infusion solutions; drugs and nursing visits may be billed separately as applicable.

inv-112: Prior authorization / ESRD labeling

DefinitionEntries annotate whether a HCPCS J‑code requires prior authorization, is assigned to the pharmacy benefit, and include brief drug/descriptive notes (ESRD labeling present).

ExamplesJ0604 annotated 'No Prior Authorization Required' for cinacalcet (ESRD on dialysis); J0602 annotated 'Prior Authorization Required = Pharmacy Benefit'.

Practical noteCheck both PA and benefit assignment fields on each line—some codes show combined flags (e.g., 'Prior Authorization Required = Pharmacy Benefit').

inv-113: Pharmacy Benefit

DefinitionIndicates the J‑code or drug is managed under the pharmacy benefit (may change PA rules or exclude medical PA).

ExamplesSeveral entries in the J75xx and J86xx ranges are marked 'Pharmacy Benefit' (e.g., J7515, J7516).

Billing implicationPharmacy Benefit assignment may require providers to follow pharmacy prior authorization or dispensing processes rather than medical PA workflows.

inv-114: Not Covered

DefinitionExplicit denial designation in the list meaning the payer will not cover that HCPCS code/formulation under the referenced benefit.

ExamplesSpecific entries shown as Not Covered include certain compounded inhalation solutions (e.g., J7632, J7634, J7638) and some CGM accessory codes (A9276–A9278).

Provider guidanceDo not bill or expect payment for codes marked Not Covered; discuss alternative covered therapies or formulary options with the payer or patient.

inv-115: Pharmacy Benefit

DefinitionPharmacy Benefit designation for listed entries (repeat confirmation across table segments).

ExampleMultiple entries across the document reiterate Pharmacy Benefit mapping for certain J‑codes and oral/infusible products.

Operational noteWhen 'Pharmacy Benefit' is shown, check the applicable pharmacy prior auth and dispensing rules before billing under the medical benefit.

inv-116: Prior Authorization status

DefinitionNo Prior Authorization Required / Prior Authorization Required indicates whether prior authorization is needed for the listed HCPCS J‑code or drug product.

UsageEach line in the HCPCS table uses this PA status field to guide provider action (examples across J060x, J157x, J28xx, etc.).

ActionAlways follow the per‑line PA status when preparing claims or requesting prior authorizations to avoid denials or incorrect routing.

inv-117: M0220 / M0221

DefinitionM0220 / M0221 refer to injection of tixagevimab and cilgavimab for pre‑exposure prophylaxis in specified patients (age and weight criteria noted).

Key criteriaUsed for pre‑exposure prophylaxis in eligible individuals (>=12 years and >=40 kg) who are moderately to severely immunocompromised or have contraindication to vaccination; includes post‑administration monitoring.

PA statusThese M‑codes are shown as No Prior Authorization Required in the excerpt for the described use.

inv-118: M0249 / M0250

DefinitionM0249 / M0250 denote intravenous infusion of tocilizumab for hospitalized patients with COVID‑19 (first and second dose) including monitoring.

PopulationHospitalized adults and pediatric patients (>=2 years) receiving systemic corticosteroids and requiring supplemental oxygen or mechanical support.

PA statusThese M‑codes are shown as No Prior Authorization Required in the excerpt for the specified inpatient COVID‑19 indication.

inv-119: pre-exposure prophylaxis

DefinitionPre‑exposure prophylaxis: administration of specified monoclonal antibodies to prevent infection in high‑risk individuals prior to exposure.

Example codesM0220/M0221 and Q0220/Q0221 range map to tixagevimab/cilgavimab (Evusheld) for pre‑exposure prophylaxis as annotated in the table.

DocumentationEntries include indication text and monitoring requirements in the table (see M0221 and related Q‑code lines).

inv-120: Prior Authorization Required

DefinitionAnnotation indicating whether prior authorization is required for billing/coverage of the listed injectable (map field 'Prior Authorization Required').

ExampleMultiple Q‑ and M‑codes show 'Prior Authorization Required = No Prior Authorization Required' variants; check per‑line mapping.

Provider actionFollow the per‑code Prior Authorization Required field when submitting authorization requests or claims.

inv-121: Home infusion therapy per diem

DefinitionHome infusion therapy per diem: per‑day billing for home infusion services including administrative and professional pharmacy services; drugs and nursing billed separately.

Example codesS5501, S5502 and S9325–S9331 are used to bill home infusion per‑diem services with PA status indicated per line.

Billing notePer‑diem codes cover administrative/pharmacy services; actual drug and nursing visits are coded and billed separately as noted in the table.

inv-122: Insulin cartridge/pen

DefinitionInsulin cartridges and disposable insulin delivery pens are listed with unit sizes and prior authorization statuses in the table.

ExamplesS5566 (insulin cartridge 300 units), S5570 and S5571 (insulin disposable pen sizes 1.5 ml and 3 ml) are shown with No Prior Authorization Required in the excerpt.

Operational noteVerify unit size and PA mapping on the exact S‑code line when billing insulin supplies/pen cartridges.

inv-123: No Prior Authorization Required

DefinitionNo Prior Authorization Required — annotation indicating the listed code does not require prior authorization per this segment.

ExamplesDocument includes many 'No Prior Authorization Required' entries (e.g., J0601–J0608, J0615, S5570, 90382, 91323).

ActionProviders may proceed to bill without PA for codes explicitly annotated No Prior Authorization Required in the payer's table.

inv-124: Prior Authorization Required

DefinitionPrior Authorization Required — annotation indicating the listed code requires prior authorization per this segment.

ExamplesMultiple entries such as J9054, J9161, J7169 and many Q‑codes are marked Prior Authorization Required in the excerpts.

Provider implicationObtain and document PA approval prior to service to reduce denials for codes with this annotation.

inv-125: No Prior Authorization Required

DefinitionNo Prior Authorization Required — simple status note repeated across table segments indicating no PA needed for the listed code.

ExamplesSeen across vaccine administration, ESRD infusion, and select J‑code entries (e.g., 0054A[4], 0064A[4], J0601).

GuidanceConfirm the specific line in the payer table; if listed as No Prior Authorization Required, submit claim without PA.

inv-126: Prior Authorization Required

DefinitionPrior Authorization Required — annotation indicating PA is required for the listed code in this segment of the payer's mapping.

ExamplesNumerous high‑cost J‑codes, coagulation factors, and specialized biosimilars are flagged as Prior Authorization Required in the tables.

RecommendationSubmit PA requests with supporting clinical documentation per payer requirements before performing billed services for these codes.

inv-127: Not Covered

DefinitionNot Covered — annotation indicating the listed code/product is not covered by the payer for the referenced formulation or use.

ExamplesCGM transmitter/receiver accessories (A9277, A9278) and several compounded inhalation solutions (J7632–J7643 groups) are explicitly listed Not Covered.

ConsequenceClaims for Not Covered items will be denied; providers should identify covered alternatives or coordinate patient financial responsibility discussions.

Policy Summary

PayerCareSource Georgia

PolicyCPT/HCPCS code coverage and prior authorization statuses (partial table)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionCheck the per‑code table to confirm whether a specific HCPCS/CPT entry requires prior authorization or is routed to the pharmacy benefit before billing.

SourceLink

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CPT/HCPCS code coverage and prior authorization statuses (partial table)

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Coverage and Prior Authorization Criteria (excerpt)

Partial code coverage table (excerpt)

Coverage and prior authorization statuses shown for listed codes in these chunks.

ALL of the following

Examples (one or more):
- 90378 — listed with Prior Authorization Required in this fragment (vaccine/antibody administration mapping).
  See vaccine/antibody administration code entries.
- 90380 — No Prior Authorization Required (RSV/monoclonal antibody seasonal dose mapping).
  RSV monoclonal antibody seasonal dose mapping.
- 90381 — No Prior Authorization Required (RSV/monoclonal antibody seasonal dose mapping).
  RSV monoclonal antibody seasonal dose mapping.
- 90584 — No Prior Authorization Required (rabies vaccine/administration mapping shown as No Prior Authorization Required).
  Vaccine administration entry.
Note: the table includes many CPT/HCPCS vaccine and administration codes with mixed PA designations; users should consult the specific line item for each code.
Entries are shown in the cited chunks (partial table).

ALL of the following

0054A[4], 0064A[4], 0094A[4], 90480 — COVID-19 vaccine administration codes shown as No Prior Authorization Required in these chunks.
See administration code lines in chunk 3.

ALL of the following

90683 — marked Not Covered in this fragment (RSV mRNA LNP vaccine entry).
See chunk 5 for Not Covered annotation.
Multiple 9131x–91317 entries — shown as No Prior Authorization Required for bivalent and related COVID-19 vaccine presentations in this segment.
See chunk 5.

CGM coverage excerpt

CGM-related coverage determinations present in table.

ANY of the following

A4222/A4223 — Supply allowance for adjunctive, non-implanted continuous glucose monitor (CGM); listed as Prior Authorization Required.
Adjunctive CGM supply allowance flagged for PA in chunk 7.
A4239 — Non-adjunctive, non-implanted CGM supply allowance (Freestyle Libre/Dexcom) assigned to Pharmacy Benefit and shown as No Prior Authorization Required (Pharmacy Benefit).
Chunk 7 marks A4239 as Pharmacy Benefit / No PA.
A9276 / A9277 / A9278 — Simplera and related CGM sensors/transmitters/receivers listed as Not Covered in this fragment.
See chunk 7 and chunk 8 for Not Covered annotations.

Operational note: the table differentiates adjunctive vs non-adjunctive CGM supplies and may route some lines to the pharmacy benefit; verify benefit routing when billing.

See chunk 7 (benefit assignments).

PA and benefit designations for listed J-codes (partial)

Per the excerpt, each J-code is paired with a designation indicating prior authorization status or benefit type and a mapping to a specific drug product.

ANY of the following

J0134 / J0136 / J0137 / J0138 — Acetaminophen injection variants shown as No Prior Authorization Required in this fragment (manufacturer-specific mappings noted).
Chunk 18 lists J0134–J0138 as No Prior Authorization Required.
J0139 — mapped to adalimumab (1 mg) and designated as Pharmacy Benefit in this fragment; PA routing may follow pharmacy rules.
Chunk 18 shows J0139 mapped and routed to Pharmacy Benefit.
J0174 / J0177 / J0178 / J0179 — Selected ophthalmologic biologics (e.g., lecanemab/Leqembi, aflibercept/Eylea HD, brolucizumab/Beovu) are indicated as Prior Authorization Required on the listed lines.
Chunk 21 marks these J017x entries as Prior Authorization Required in the mapping.
J0604 — Cinacalcet (Sensipar) mapped for ESRD-on-dialysis use and shown as No Prior Authorization Required in this fragment; other J060x entries vary by PA/pharmacy benefit.
Chunk 36 shows J0604 as No Prior Authorization Required while other J060x lines differ.
J0606 — Etelcalcetide (Parsabiv) listed as Prior Authorization Required in this segment.
Chunk 36 shows J0606 = Prior Authorization Required.

See chunks 18, 21, 36 for per-line examples.

Coverage annotations (prior auth / no prior auth / equivalency)

Coverage-related annotations found in these chunks are limited to prior authorization requirements and therapeutic equivalency notes for J-codes.

ALL of the following

Prior authorization examples:
- J0602 / J0603 — shown with Prior Authorization Required and assigned Pharmacy Benefit in some lines.
  Chunk 36 shows J0602/J0603 PA = Pharmacy Benefit.
- J0606 — listed as Prior Authorization Required (example from the J06xx group).
  Chunk 36 shows J0606 = Prior Authorization Required.
No prior authorization examples:
- J0612 / J0613 / J0652 — explicitly shown as No Prior Authorization Required in these lines.
  Chunk 38 shows J0612/J0613 as No Prior Authorization Required; chunk 41/51 include J0652.
Therapeutic equivalence notes:: Multiple entries (e.g., daptomycin-related lines) specify 'not therapeutically equivalent' relationships among manufacturer-specific products, indicating they should not be treated as interchangeable for PA/coverage decisions.
See chunk 51 and related entries for 'not therapeutically equivalent' annotations.

Operational note: PA and benefit designation can differ even within a J-code family depending on manufacturer/NDC mappings; therapeutic equivalence statements affect substitution and PA decisions.

Based on chunks 36, 38, 51.

Prior authorization‑based coverage criteria (partial)

Coverage stance indicated by prior authorization flags for specialty and gene therapy injections in this segment.

ALL of the following

Gene therapy J-codes (examples: J1411–J1414, J1426–J1430) — listed as Prior Authorization Required in this fragment (gene/specialty therapy entries).
Chunk 64 indicates these J14xx entries are Prior Authorization Required.
Selected specialty injectables and IV iron/ferric products (e.g., J1437, J1439, J1440–J1444 entries) — many lines are marked Prior Authorization Required; some related ferric products show Pharmacy Benefit or other dispositions.
Chunk 65 shows J1437/J1439/J1440-J1444 with PA indications.
Operational note: specialty gene- and cell-therapy entries are consistently flagged for prior authorization in this range—providers should expect PA requirements for these high-cost products.
Chunks 64–65.

Exception note: some closely related small entries (e.g., J1434) are shown No Prior Authorization Required — review each line item for exceptions.

See chunk 64 (J1434 = No Prior Authorization Required).

Partial coverage criteria from excerpt

Coverage stance varies by J-code; entries explicitly label whether prior authorization is required or not and sometimes indicate pharmacy benefit routing.

ALL of the following

J1570–J1576 (Triferic and related mappings) — multiple J157x entries shown as Prior Authorization Required for several Triferic mappings (J1571–J1576).
Chunks 72–73 show J1571–J1576 marked Prior Authorization Required.
J1580–J1596 — mixed routing: many entries are routed to the Pharmacy Benefit and listed as No Prior Authorization Required (Pharmacy Benefit), while some codes (e.g., J1599) are shown as Prior Authorization Required.
Chunk 73 indicates mixed PA/Pharmacy Benefit for J1580–J1596.
Insulin pump-related J-codes (J1811–J1815) — generally require Prior Authorization for insulin intended for pump use; several insulin pump entries are explicitly Prior Authorization Required.
Chunk 83 lists J1811–J1815 with PA required for pump-use insulin.

Chunks 72–83.

Per-J-code authorization criteria (excerpt)

Per-code prior authorization stance as listed in these chunks.

ANY of the following

J2184 — Prior Authorization Required (meropenem mapping, manufacturer-specific non-equivalence noted).
Chunk 90 lists J2184 = Prior Authorization Required.
J2185 — No Prior Authorization Required (alternative meropenem mapping shown).
Chunk 90 shows J2185 = No Prior Authorization Required.
J2310 — No Prior Authorization Required (naloxone mapping).
Chunk 95 shows J2310 = No Prior Authorization Required.
J2506 — Prior Authorization Required (pegfilgrastim / related colony-stimulating agent entries shown elsewhere in the table).
Chunk 111/101 indicate pegfilgrastim lines with PA required; chunk 90 references colony-stimulating agents overall.

Note: status varies by J-code and product—these per-code examples are taken directly from the cited chunks; consult the full line item for each HCPCS code before billing.

Chunks 90, 95, 109.

Per-code coverage stance (partial)

Stated coverage stance per J-code in this section is limited to simple PA requirement flags and benefit assignment (e.g., Pharmacy Benefit).

ANY of the following

Range J2786–J2805 — mixed stance per line: some specific J2786/J2787/J2788 entries are No Prior Authorization Required while adjacent codes (e.g., J2790) require Prior Authorization.
Chunk 108 and 109 show mixed PA statuses within this range.
J2941 — marked as Pharmacy Benefit in the listing.
Chunk 111 indicates J2941 = Pharmacy Benefit.
J3590 — unclassified biologics: multiple high‑cost gene/cell therapies recorded under J3590 are generally shown with Prior Authorization Required in many entries; a specific exception is noted for Avastin when used for eye injections (No Prior Authorization Required).
Chunk 125 documents J3590 PA nuance (Avastin eye injections exception).
J7030–J7100 — infusion normal saline/dextrose ESRD fluids are marked No Prior Authorization Required in this segment.
Chunk 127 lists these infusion codes as No Prior Authorization Required.

Chunks 125 and 127.

Code-level coverage stances (partial)

Stated coverage stance by HCPCS code in this segment

ANY of the following

J7030 — No Prior Authorization Required (normal saline infusion; ESRD-on-dialysis use noted).
Chunk 127 shows J7030 = No Prior Authorization Required.
J7169 — Andexxa (andexanet alfa) listed with Prior Authorization Required annotation in this fragment.
Chunk 129 indicates J7169 listed with Prior Authorization Required in some lines.
J7311 (and related hyaluronan/implant entries) — Prior Authorization Required for many listed implant/hyaluronan products in this range.
Chunk 136/144 indicate PA for hyaluronan/implant products such as J7311/J7322–J7323.

Note: these code-level stances are excerpts—adjacent or manufacturer‑specific lines may carry different PA instructions or pharmacy benefit routing.

Chunks 127, 129, 136.

HCPCS coverage mappings (partial)

Coverage stance for specific HCPCS J‑codes as listed in this segment.

ANY of the following

Prior Authorization Required: Examples: J7336, J7340, J7342, J7345, J7352, J7353 — these J‑codes are listed as Prior Authorization Required in this segment.
Chunk 144 shows J7336, J7340, J7342/J7345, J7352/J7353 with PA required.
Pharmacy Benefit / No PA: Examples: J7515, J7599, J7601–J7606 — some codes are designated Pharmacy Benefit and/or No Prior Authorization Required per these lines.
Chunks 149 and 144 indicate Pharmacy Benefit / No PA mappings for select entries.
Not Covered: Examples: J7632, J7634, J7638 — certain compounded inhalation solutions and related entries are explicitly marked Not Covered.
Chunk 156 lists J7638 (and related J7632/J7634) as Not Covered.

Operational note: the segment includes explicit 'Not Covered' annotations for some compounded products—these indicate denial/coverage risk for those formulations.

Chunk 156.

Per‑code authorization/coverage nodes (excerpt)

Per‑code coverage/authorization indications present in this segment (examples only; not a complete list):

ANY of the following

Coverage decision: No Prior Authorization Required (entry marked as Pharmacy Benefit in the line).
Chunk 162 shows J8541 annotation.
Coverage decision: Prior Authorization Required for some codes in this antiemetic/related group (status varies by specific line).
Chunk 162–164 show mixed PA within the J86xx range.
Coverage decision: Prior Authorization Required (manufacturer/therapeutic equivalence notes affect PA requirement).
Chunk 168 references J9046 with Prior Authorization Required and therapeutic non-equivalence notes.

Note: these per-code nodes are illustrative; the full table contains many more J-code lines with mixed PA and benefit assignments.

Chunks 162–164.

Stated prior authorization stance for sampled codes

Stated coverage/authorization stance for select codes in this extract:

ANY of the following

Stance: Prior Authorization Required (enfortumab vedotin mapping).
Chunk 180 lists J9249 = Prior Authorization Required.
Stance: No Prior Authorization Required (example meropenem/methotrexate mapping line showing No PA).
Chunk 180 shows J9255 with No Prior Authorization Required in part of the line.
Stance: No Prior Authorization Required (tixagevimab and cilgavimab pre-exposure prophylaxis administration mapping).
Chunk 196 indicates M0220 = No Prior Authorization Required.
Stance: No Prior Authorization Required (home administration mapping noted).
Chunk 196 shows M0221 = No Prior Authorization Required.
Stance: No Prior Authorization Required (tocilizumab infusion for hospitalized COVID-19 patients — first dose).
Chunk 196/199 show M0249 = No Prior Authorization Required.
Stance: No Prior Authorization Required (tocilizumab second dose).
Chunk 199 shows M0250 = No Prior Authorization Required.

Operational reminder: COVID-19–related M-codes in this extract are explicitly shown as not requiring prior authorization; confirm clinical eligibility criteria when scheduling administration.

Chunks 196–199.

Coverage notes for listed injectables

Coverage stance and prior authorization notes for listed injectable products and biosimilars in this section.

ANY of the following

Multiple M- and Q-codes (examples: M0222, M0223, Q0220, Q0222, Q0249) are indicated as No Prior Authorization Required for the monoclonal antibody/admin infusion lines in these chunks.
Chunks 198, 206 show many M/Q codes with No Prior Authorization Required.
Some Q-codes (e.g., Q0139 for ferumoxytol-like entries) are explicitly marked Prior Authorization Required — PA varies by product.
Chunk 206 indicates some Q-codes are PA required (e.g., ferumoxytol references).
Biosimilar Q-code mappings (examples in the Q5100–Q5130 range) show mixed PA statuses: many lines alternate between No Prior Authorization Required and Prior Authorization Required depending on the specific biosimilar and listing.
Chunk 212 documents mixed PA assignments for biosimilar Q-codes.

Operational note: biosimilar and monoclonal antibody entries in the Q-code range should be checked per-code for PA status and benefit routing prior to procurement or billing.

Chunks 198, 206, 212.

Q-code PA mapping fragment

Q-code biosimilar products

ALL of the following

Mapped Q-code examples (PA variation):
- Q5116 / Q5117 — mapped to Trazimera/Kanjinti (biosimilar injectables) with supply fee annotations; PA status varies by line.
  Chunk 216 lists Q5116/Q5117 mapping to Trazimera/Kanjinti.
- Q5119 / Q5120 — Ruxience and Ziextenzo biosimilars are shown with lines alternating between No Prior Authorization Required and Prior Authorization Required.
  Chunks 216–217 show Q5119/Q5120 with mixed PA annotations.
- Q5121–Q5130 — Additional biosimilar mappings (Avsola, Nyvepria, Riabni, Byooviz, Releuko, Stimufend, Cimerli, Vegzelma, Fylnetra) with mixed PA assignments; some lines explicitly show 'No Prior Authorization Required = Prior Authorization Required' indicating variance across listings.
  Chunks 217–218 document mixed PA patterns across Q5121–Q5130.
Rule: each Q-code line in this range maps a Q-code to a biosimilar product and records an explicit PA status or benefit assignment; verify the exact Q-code line when determining authorization needs.
Chunks 216–218.

Provider action: check the specific Q-code line for the biosimilar being administered to determine whether prior authorization is required or whether the item is processed under the pharmacy benefit.

Chunks 216–218.

S-code coverage fragment

Home infusion and supply coverage indicators

ALL of the following

S-code examples (mix of PA statuses):
- S0179 / S0197 — No Prior Authorization Required for selected home infusion/home therapy per‑diem and related services.
  Chunk 231–232 show S0179/S0197 with No Prior Authorization Required.
- S5498 / S5501 / S5502 — Home infusion catheter care/maintenance codes are shown with Prior Authorization Required for many complex/implanted access device service lines.
  Chunk 232–233 show S5498/S5501/S5502 with PA required for complex care codes.
- S5550–S5571 / S5566 — Insulin supply and insulin cartridge/pen codes: many lines are No Prior Authorization Required for cartridges and disposable pens; specific entries (S5566, S5570, S5571) show No PA in this excerpt.
  Chunks 232–234 list insulin supply S-codes and No PA annotations.
- S9325 / S9326 / S9327 / S9328 / S9329 / S9330 / S9331 — Home infusion per‑diem codes for pain, chemotherapy and continuous therapy range between No Prior Authorization Required and Prior Authorization Required depending on intensity/duration (e.g., S9326 and S9330 flagged Prior Authorization Required for continuous services).
  Chunks 234–235 show mixed PA for S93xx series.
Note: each S-code entry includes a short service descriptor and an explicit PA flag in the table—verify the exact S-code and service frequency/duration when assessing authorization requirements.
Chunks 231–235.

Provider reminder: home infusion per‑diem codes often require documentation of clinical necessity and care setting; codes flagged PA will need prior authorization before reimbursement.

Chunks 231–235.

Per-code PA stance (examples)

Per-code authorization stance and brief service descriptor entries

Chunk 247 guidance implied by PA flags for high-cost items.

Code-level coverage annotations

Coverage stance for codes in this segment is expressed directly as annotations next to each code (e.g., 'No Prior Authorization Required', 'Prior Authorization Required', 'Not Covered').

Operational reminder: the table is partial — verify full policy table for codes not shown here before assuming No PA or Not Covered status.

Chunks 255–262 and inventory metadata.

Code Tables and Mappings (excerpt)

COVID-19 vaccine administration codesCPTCovered

0054A[4]	Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted administration - Booster
0064A[4]	Moderna Covid-19 Vaccine (Low Dose) administration - Booster
0094A[4]	Moderna Covid-19 Vaccine (Aged 18+) administration - Booster
90480	Immunization administration by intramuscular injection of SARS-CoV-2

RSV vaccine codesCPT

90678	Respiratory syncytial virus vaccine, preF, subunit, bivalent
90679	Respiratory syncytial virus vaccine, preF, recombinant, adjuvanted - marked Not Covered
90683	Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use (some entries marked Not Covered)

CGM device/sensor codesHCPCS

A4239	Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM) - Pharmacy Benefit / No Prior Authorization Required
A9276	Simplera continuous glucose monitor sensor; sensor, invasive, disposable - Not Covered

J013x mappingsHCPCSCovered

J0134	Injection, acetaminophen, 10 mg (mapped to acetaminophen injection - Fresenius Kabi); No Prior Authorization Required
J0136	Injection, acetaminophen, 10 mg (mapped to acetaminophen injection - B. Braun); No Prior Authorization Required
J0137	Injection, acetaminophen, 10 mg (mapped to acetaminophen injection - Hikma); No Prior Authorization Required
J0138	Injection, acetaminophen 10 mg and ibuprofen 3 mg; No Prior Authorization Required
J0139	Injection mapped to adalimumab, 1 mg; designated Pharmacy Benefit

Selected ophthalmologic/neuro biologicsHCPCSCovered

J0174	Injection, lecanemab-irmb, 1 mg (Leqembi); listed as Prior Authorization Required
J0177	Injection, aflibercept HD, 1 mg (Eylea HD); listed as Prior Authorization Required
J0178	Injection, aflibercept, 1 mg; Prior Authorization Required
J0179	Injection, brolucizumab-dbll, 1 mg (Beovu); Prior Authorization Required

ESRD-related medications mapped to J060xHCPCSCovered

J0604	Cinacalcet, oral, 1 mg (Sensipar) for ESRD on dialysis; listed as No Prior Authorization Required in this fragment
J0606	Injection, etelcalcetide, 0.1 mg (Parsabiv); listed as Prior Authorization Required

J06xx group mappings and notesHCPCS

J0601	Injection, daxibotulinumtoxina-lanm mapped to sevelamer carbonate 20 mg (ESRD on dialysis)
J0602	Injection mapped to Sevelamer carbonate powder 20 mg; Prior Authorization Required = Pharmacy Benefit
J0606	Injection, etelcalcetide, 0.1 mg (Parsabiv); Prior Authorization Required

Selected J-code clusters (levothyroxine-related and daptomycin/ESA-related)HCPCS

J0650-J0717 (selected examples)	Multiple levothyroxine sodium J-code mappings (J0650-J0717) with therapeutic equivalence notes (selected examples)
J0872-J0896 (selected examples)	Daptomycin and related ESA mappings; prior authorization statuses vary by code (selected examples)

Selected J‑codes and descriptions (partial)HCPCS

J0896	Luspatercept‑aamt injection (listed alongside daptomycin mappings) with mixed PA indications
J0898	Denosumab injection (entries reference argatroban and daptomycin comparisons)
J1160	Digoxin injection / digoxin immune fab references (listed in this segment)

Gene therapy / specialty J‑codesHCPCSCovered

J1411	Etranacogene dezaparvovec‑drlb (Hemgenix) per therapeutic dose; Prior Authorization Required noted for gene therapy J-codes
J1412	Valoctocogene roxaparvovec (Roctavian) per ml; Prior Authorization Required indicated
J1413	Delandistrogene moxeparvovec (Elevidys) per therapeutic dose; Prior Authorization Required indicated
J1414	Fidanacogene elaparvovec (Beqvez) per therapeutic dose; listed as Prior Authorization Required

Example J157x mappingsHCPCS

J1570	Triferic / ferric pyrophosphate citrate solution mapping and prior auth note
J1571	Related immune globulin mapping; Prior Authorization Required for several J157x entries

Insulin pump J-codesHCPCS

J1811	Fiasp insulin for pump use; Prior Authorization Required
J1812	Fiasp/Lyumjev insulin pump entries; Prior Authorization Required

Sample antimicrobial J-codes and statusesHCPCS

J2021	Zyvox (line entry) — No Prior Authorization Required for some entries
J2184	Meropenem (B. Braun) — Prior Authorization Required indicated
J2185	Merrem (meropenem) — No Prior Authorization Required indicated

Colony-stimulating / biologic agentsHCPCS

J2506	Pegfilgrastim (excludes biosimilar) — Prior Authorization Required indicated
J2507	Pegloticase — Prior Authorization Required indicated

Triamcinolone & related injectablesCPT

J3301-J3315

Triamcinolone acetonide formulations and related injectable ophthalmic/musculoskeletal products (Xipere, Triesence, Zilretta) with mixed PA requirements

Unclassified biologics / gene therapiesCPT

J3590

Unclassified biologic/drug code used for multiple high-cost gene and cell therapies (examples: betibeglogene, elivaldogene, exagamglogene, lovo-cel) with PA required in many entries

Infusion / ESRD fluidsCPT

J7030-J7100

Unclassified infusion codes for normal saline and dextrose solutions used for ESRD/dialysis (examples: normal saline solution infusions) - No Prior Authorization Required

Selected saline/dextrose infusionsHCPCSCovered

J3590	Unclassified code usage examples (magnesium sulfate / potassium chloride entries noted)
J7030	Infusion, normal saline solution, 1000 cc — No Prior Authorization Required
J7042	Infusion, 5% dextrose/normal saline (500 ml = 1 unit) — No Prior Authorization Required
J7060	Infusion, 5% dextrose/water (250 cc) — No Prior Authorization Required

Coagulation factors and reversal agentsHCPCSCovered

J7169	Andexxa (andexanet alfa) — Prior Authorization Required
J7170	Hemlibra (emicizumab) — Prior Authorization Required
J7177	Fibryga / RiaStap / Vonvendi and other factor/fibrinogen products — Prior Authorization Required

Selected J‑codes with PA and mapped productsHCPCSCovered

J7336	Mapped examples (e.g., Qutenza/capsaicin 8% patch) — Prior Authorization Required
J7340	Mapped to Duopa and other enteral suspensions — Prior Authorization Required
J7352	Mapped to Scenesse/Nexobrid and others — Prior Authorization Required

Examples of Not Covered compounded inhalation solutionsHCPCSNot Covered

J7632	Cromolyn sodium inhalation solution, compounded unit — Not Covered
J7634	Budesonide inhalation solution, compounded — Not Covered

Representative J‑codes and drug descriptionsHCPCS

J8541	Dexamethasone (hemady) / antiemetic drug entries (example mapping)
J8560	Etoposide; oral, 50 mg (antineoplastic/antemetic group entries)
J8650	Netupitant 300 mg + palonosetron 0.5 mg (Akynzeo) and other antiemetic entries

Additional oncology injectable J‑codesHCPCS

J9040	Bleomycin sulfate injection; bortezomib 0.1 mg; brentuximab vedotin, 1 mg
J9100	Cytarabine, 100 mg; related oncology injectables
J9218	Leuprolide acetate, per 1 mg (example oncology injectable mapping)

Oncology-related injectable J-codes and mappings (partial)CPT

J9280-J9305 (examples)

Codes mapped to tisotumab vedotin-tftv, tebentafusp-tebn, pemetrexed, pembrolizumab and related agents (examples)

Misc. M-codes for home administration and COVID-19 therapiesHCPCS

M0201-M0250 (examples)

Home vaccine administration and monoclonal antibody infusion/admin codes (COVID-19 related); M0201/M0220–M0250 entries shown with No Prior Authorization Required in many instances

Selected M- and Q-codesmixedCovered

M0222	Bebtelovimab injection (mapped in text); No Prior Authorization Required indicated in entries
M0249	Tocilizumab infusion for hospitalized COVID-19 patients (first dose) — No Prior Authorization Required
M0250	Tocilizumab second dose — No Prior Authorization Required
Q0222	Bebtelovimab 175 mg injection — No Prior Authorization Required
Q0220	Tixagevimab and cilgavimab (Evusheld) for pre-exposure prophylaxis — No Prior Authorization Required

Biosimilar product codesmixedCovered

Q5101	Filgrastim-sndz (Zarxio) injection, 1 mcg — biosimilar mapping
Q5103	Infliximab-dyyb (Inflectra) injection, 10 mg — biosimilar mapping
Q5105	Epoetin alfa-epbx (Retacrit) injection, 100 units (ESRD on dialysis) — biosimilar mapping
Q5112	Trastuzumab-dttb (Ontruzant) injection, 10 mg — biosimilar mapping

Q-code biosimilars (partial)mixed

Q5116	Trazimera / Kanjinti — biosimilar injectable, 10 mg
Q5119	Ruxience (rituximab-pvvr) biosimilar, 10 mg
Q5120	Ziextenzo (pegfilgrastim-bmez) biosimilar, 0.5 mg
Q5121	Avsola (infliximab-axxq) biosimilar, 10 mg
Q5122	Nyvepria — pegfilgrastim-apgf biosimilar, 0.5 mg

Home infusion and insulin supply S-codes (partial)mixedCovered

S5501	Home infusion therapy, catheter care/maintenance, complex — per diem (Prior Authorization Required indicated)
S5502	Home infusion therapy, implanted access device — per diem (Prior Authorization Required indicated)
S5550	Insulin, rapid onset (e.g., lispro/aspart); unit-based supply mapping
S5571	Insulin delivery device, disposable pen (1.5 ml or 3 ml) — No Prior Authorization Required indicated
S9329	Home infusion therapy, chemotherapy infusion — per diem (No Prior Authorization Required indicated for some entries)

example S- home infusion servicesHCPCSCovered

S9353	Home infusion therapy, continuous insulin infusion therapy; per diem
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services and supplies — per diem

example C-/J- injections and biologicsmixedCovered

C9301	Obecabtagene autoleucel, up to 400 million CD19 CAR-positive viable T cells, per therapeutic dose — Prior Authorization Required
J0281	Injection, aminocaproic acid, 1 gram

Selected HCPCS mappingsHCPCS

J9054	Mapped to product NIKTIMVO / BORUZU; injection mapping shown (Prior Authorization Required)
J9161	Mapped to product NIKTIMVO / LYMPHIR 300MCG; injection mapping shown (Prior Authorization Required)
Q5147	Mapped to product NIKTIMVO / PAVBLU; aflibercept-ayyh biosimilar mapping (Prior Authorization Required)

Drug/therapeutic equivalence and benefit mappingsmixed

J0601-J0618	Multiple J06xx codes for oral agents (sevelamer, lanthanum, sucroferric, ferric citrate) with notes indicating No Prior Authorization Required for ESRD on dialysis indications
J3373-J3374	Vancomycin-related codes mapped to various injectable therapeutics; No Prior Authorization Required indicated for some

Cell therapy / advanced productsHCPCSCovered

J3402	Remestemcel-l-rknd (Ryoncil) per therapeutic dose — Prior Authorization Required
J3403	Revakinagene taroretcel-lwey per implant — Prior Authorization Required

Provider Action Highlights and Billing Guidance

Note

Vaccine/antibody codes have mixed PA requirements

Check PA for 90378 (Prior Authorization Required) before submitting.
90380, 90381, 90584, 90675, 91304 are indicated No Prior Authorization Required in this fragment.

Billing Rule

CGM supplies — A4222 requires PA; others use pharmacy benefit or are Not Covered

Obtain prior authorization for A4222 (adjunctive non-implanted CGM supplies).
Bill A4239 under the pharmacy benefit (no prior auth per table).
Do not bill A9276–A9278 (marked Not Covered).

Prior Authorization

High-cost injectables and radiotherapeutics require prior authorization

Multiple high-cost injectables and radiotherapeutics in the listing are designated Prior Authorization Required; obtain PA before administration/billing for these products.

Examples annotated Prior Authorization Required include A9513/A9606, A9615, C9088–C9092/C9143–C9173 entries.
Refer to per-code lines in chunks 11–13 for radiotherapeutic and high-cost injectable PA designations.

Billing Rule

Selected J013x: most are No PA; J0139 mapped to Pharmacy Benefit

Several J013x entries are documented as No Prior Authorization Required; J0139 is routed to the Pharmacy Benefit. Verify per-line status before claim submission.

J0134, J0136, J0137, J0138 — listed as No Prior Authorization Required in the table.
J0139 is designated 'Pharmacy Benefit' in adjacent mappings; bill via pharmacy benefit if applicable.

Prior Authorization

J017x–J0180 entries now show Prior Authorization Required

J0174 (lecanemab/Leqembi) — Prior Authorization Required.
Several adjacent J0177–J0180 entries also transition to Prior Authorization Required; check each J-code's line-level annotation.

Billing Rule

J060x series — mixed PA and pharmacy benefit assignments; confirm per-code

J0602/J0603/J0605/J0607 are shown with Pharmacy Benefit or Prior Authorization Required annotations.
J0604 (cinacalcet/Sensipar) is shown as No Prior Authorization Required in one fragment — confirm ESRD indication mapping when billing.

Billing Rule

Per-code prior authorization indicators vary (example: J0602, J0606)

Use the table entry for the exact PA/benefit mapping (some codes marked 'Prior Authorization Required = Pharmacy Benefit').
Do not assume uniform PA across the J060x range; follow per-code notes.

Billing Rule

Multiple J-codes are listed No Prior Authorization Required — confirm line-level status

J0612 and J0613 — listed No Prior Authorization Required.
J0630/J0636/J0637/J0638 — entries annotated No Prior Authorization Required in this fragment.

Prior Authorization

Per-J-code PA statuses — some J-codes changed PA status (e.g., J0896/J0898)

J0896 and J0898 have line-level PA annotations (table shows changes).
Always reference the code-specific row for current PA status before billing.

Prior Authorization

Gene therapy/specialty J-codes are Prior Authorization Required

Gene therapy and specialty J-codes (e.g., J1411–J1414, J1426–J1430) are explicitly marked Prior Authorization Required in the table; obtain authorization for these high-cost specialty therapies.

J1413/J1414 and J1426–J1429 examples are annotated Prior Authorization Required.
Treat all gene therapy J-codes as requiring prior authorization unless the line indicates otherwise.

Prior Authorization

J157x entries (Triferic) require prior authorization

Multiple J157x lines (Triferic and related mappings) are annotated Prior Authorization Required; J1571–J1576 entries indicate PA is required per table.

J1571–J1576 — Prior Authorization Required for Triferic and mapped immune globulin products.
Follow the per-code PA requirement when billing Triferic-related injections.

Billing Rule

J1580–J1599: mixed PA and pharmacy benefit assignments

J1580–J1595 lines are shown with Pharmacy Benefit/No Prior Authorization Required annotations.
J1599 and select entries remain Prior Authorization Required; check each row before billing.

Prior Authorization

Insulin-for-pump and certain biologic J-codes require PA

J1811–J1814 annotated Prior Authorization Required for insulin pump administration (Fiasp, Lyumjev).
Inebilizumab (J1823 etc.) is listed with Prior Authorization Required annotations.

Documentation Required

Labetalol and related entries — mixed PA and equivalence notes

Review therapeutic equivalence notes — some manufacturer-specific labetalol listings are 'not therapeutically equivalent'.
Confirm PA status per exact J-code before billing labetalol/formulation entries.

Billing Rule

Sample J-code PA statuses — verify per-line before billing

J2021 marked No Prior Authorization Required in the excerpt.
J2184 is annotated Prior Authorization Required; J2185 annotated No Prior Authorization Required.

Billing Rule

Additional J-codes (e.g., J2310) may be No PA — confirm each code

Additional J-code entries show mixed PA assignments — e.g., naloxone J2310 is listed No Prior Authorization Required; other adjacent J-codes may require PA. Use the table to confirm each code.

J2310 (naloxone) — No Prior Authorization Required per table.
Check neighboring J2311–J2329 for per-code PA differences before billing.

Prior Authorization

Late-chunk J-code entries show mixed PA flags — consult per-code rows

Later J-code entries continue to mix Prior Authorization Required and No Prior Authorization Required flags (examples in J2786–J2800 block); consult the per-code listing for exact PA requirements.

J2788, J2791, J2792 noted No Prior Authorization Required; J2790 and J2797–J2799 show Prior Authorization Required in the fragment.
Follow the per-code table rows for final PA decision.

Prior Authorization

Per-J-code PA statuses (examples include J2788, J2790, J2802)

Per-J-code PA listings include explicit flags such as J2788 No Prior Authorization Required and J2790 Prior Authorization Required; follow the table entry for the exact PA designation when billing.

J2788 — No Prior Authorization Required (Rho D minidose example).
J2790 — Prior Authorization Required (full-dose Rho D immune globulin).
J2802 — Prior Authorization Required (romiplostim/Nplate).

Prior Authorization

J3590 (unclassified biologics) — PA varies by use; gene/cell therapies usually require PA

Treat J3590 entries for gene/cell therapies as likely requiring prior authorization unless the line explicitly indicates No Prior Authorization Required (e.g., Avastin for eye injections).
Document the clinical use to justify the J3590 billing and PA status.

Billing Rule

ESRD/infusion fluids (J7030–J7100 etc.) — No PA required

J7030, J7040, J7042, J7060, J7070, J7100 — No Prior Authorization Required for listed saline/dextrose infusion products.
Use ESRD-on-dialysis indication mappings shown in the table when billing these infusions.

Billing Rule

Multiple codes are explicitly No Prior Authorization Required — use table to confirm

Reference the table rows for exact code lists of No Prior Authorization Required.
Do not submit unnecessary PAs for codes explicitly marked No Prior Authorization Required.

Prior Authorization

Coagulation factors and reversal agents require prior authorization

J7169 (Andexxa) — Prior Authorization Required per table.
J7170 (Hemlibra) and numerous factor VIII/IX/fibrinogen products — Prior Authorization Required.

Billing Rule

Pharmacy benefit mappings — certain codes handled under pharmacy benefit with PA implications

Codes annotated 'Pharmacy Benefit' may require processing via the pharmacy benefit and may have different PA rules (e.g., J7294–J7307, Q5139–Q5144).
Follow the pharmacy benefit PA workflow where indicated.

Prior Authorization

Hyaluronan/implant products require prior authorization

Examples: J7316–J7326, J7336, J7340, J7342–J7345 — Prior Authorization Required.
Confirm the specific J-code's PA flag when scheduling procedures involving hyaluronan or implant products.

Denial Risk

Not Covered entries present — billing these codes poses coverage/denial risk

Several codes and code ranges are annotated Not Covered (examples include compounded inhalation solutions J7632, J7634, J7638 and related entries); billing these codes risks denial.

J7632, J7634, J7638 and similar compounded inhalation solution entries are marked Not Covered.
Avoid billing or seek prior authorization/medical review only if there is documented exception and payer guidance.

Billing Rule

COVID-19 monoclonal antibody and tocilizumab M-codes — No PA required per table

M0220/M0221 (tixagevimab/cilgavimab) — No Prior Authorization Required for listed pre-exposure prophylaxis indications.
M0222–M0223 (bebtelovimab) and M0249–M0250 (tocilizumab for hospitalized COVID-19) — No Prior Authorization Required as annotated.

Billing Rule

Q-code MAb and biosimilar PA status is mixed — confirm per-code

Q0222/Q0249 and several Q51xx–Q512x biosimilar lines are annotated No Prior Authorization Required in the excerpt.
Some Q-codes (e.g., Q0139/ferumoxytol-like entries and Q5147–Q5149) are marked Prior Authorization Required — check per-line.

Billing Rule

Q-code biosimilars — PA mappings vary by product and line

Q5119/Q5120/Q5121 and adjacent biosimilar Q-codes show line-level PA variance; verify the product-to-code mapping and PA flag.
Do not assume biosimilars have the same PA handling as innovator products — follow the table.

Billing Rule

S‑codes (home infusion/insulin supplies) — mixed PA; verify per-code

S5550–S5566 and S5571 insulin supply/cartridge/pen codes often No Prior Authorization Required.
S9326, S9330, S9331, S9345, S9346, S9347, S9348, S9336 etc. are marked Prior Authorization Required; obtain PA for continuous/complex home infusion services.

Prior Authorization

Selected J-/C- drug and biologic codes are Prior Authorization Required

C9301–C9304 (cell and advanced therapy codes) — Prior Authorization Required.
J9054, J9161 and Q5147–Q5149 — annotated Prior Authorization Required; follow per-line PA process.

Prior Authorization

Numerous HCPCS lines are annotated 'Prior Authorization Required' — obtain PA

The table includes explicit 'Prior Authorization Required' annotations for many HCPCS lines (examples: J9054, J9161, Q5147–Q5152, Q9999, Q2057); check and obtain PA where shown.

Refer to the specific HCPCS rows annotated 'Prior Authorization Required' when preparing PA requests.
Do not bill without PA for codes explicitly marked Prior Authorization Required.

Billing Rule

Explicit No Prior Authorization Required entries present — follow table

J0601–J0608 and J0615 — No Prior Authorization Required per the table.
90382 and 91323 also annotated No Prior Authorization Required.

Denial Risk

Q0224 marked Not Covered — coverage risk

Q0224 is explicitly marked Not Covered in the listing; billing this code risks denial and it should not be submitted for payment under the listed benefit.

Do not bill Q0224 — marked Not Covered in the table.
If clinically necessary, request medical policy review prior to billing for potential exception.

Note

Status Keywords and Definitions

inv-97: No Prior Authorization Required

DefinitionCode may be billed without obtaining prior authorization as indicated in the table entries.

Typical annotationDisplayed in HCPCS/CPT tables as 'No Prior Authorization Required' next to specific codes (examples: 90380, 90381, 90584, 90480).

Implication for billingProviders may submit claims for listed codes without first requesting PA from CareSource Georgia when the line lists No Prior Authorization Required.

inv-98: Prior Authorization Required

DefinitionCode requires prior authorization before coverage or payment, as indicated in the table entries.

Typical annotationDisplayed in HCPCS/CPT tables as 'Prior Authorization Required' next to specific codes (examples: many J‑codes and select high‑cost injectables such as J2802, J7169).

Implication for providersClaims for these codes may be denied or delayed unless an approved PA is obtained per the payer's process.

inv-99: Not Covered

DefinitionThe code or product is listed as Not Covered in the table and is not payable under the policy.

Typical annotationMarked explicitly as 'Not Covered' for specific formulations or compounded products (examples: 90679 RSV recombinant vaccine; J7638 and other compounded inhalation solutions).

Implication for claimsClaims submitted for items marked Not Covered will not be paid; alternative clinically appropriate options should be considered.

inv-100: No Prior Authorization Required

DefinitionIndicates the listed J‑code/drug does not require prior authorization per this fragment.

Example entriesMultiple J013x lines (J0134–J0139) are shown as No Prior Authorization Required in the table excerpt.

Provider actionNo PA submission is needed for those specific J‑code uses when billed as shown in the mapping.

inv-101: Pharmacy Benefit

DefinitionIndicates the product is administered under the pharmacy benefit rather than the medical benefit for the listed code.

Example mappingSome J06xx and J75xx entries are annotated 'Pharmacy Benefit' (e.g., J0602 = Pharmacy Benefit; J7515 marked Pharmacy Benefit).

ImplicationManagement, PA rules, or coverage routing may follow pharmacy‑benefit processes rather than medical prior authorization workflows.

inv-102: Not therapeutically equivalent

DefinitionManufacturer-specific injectable products are noted as not therapeutically equivalent to other J‑code entries and should not be treated as interchangeable.

Example noteMultiple entries state 'not therapeutically equivalent' for manufacturer variants (e.g., daptomycin Baxter entries flagged vs other J‑codes).

Clinical implicationSubstitution between listed manufacturer products may affect PA requirement or coverage; follow specified mapping in the table.

inv-103: Pharmacy Benefit

DefinitionPharmacy Benefit designation indicating the J‑code/product is handled under pharmacy rules or benefit administration.

ExampleEntries such as J0602 and J7515 are annotated as Pharmacy Benefit in the table excerpts.

NotePharmacy Benefit mapping may change the applicable PA pathway and claim routing.

inv-104: not therapeutically equivalent

DefinitionStatement that certain manufacturer's product entries are 'not therapeutically equivalent' to other J‑codes, used to prevent substitution as equivalent.

ExampleEntries for levothyroxine and daptomycin variants repeatedly note 'not therapeutically equivalent' across manufacturer mappings.

Operational impactUse the exact mapped J‑code/manufacturer entry for authorization and billing decisions rather than assuming interchangeability.

inv-105: Prior Authorization Required / No Prior Authorization Required

DefinitionFlag indicating whether prior authorization is required or not for the listed product (table shows 'Prior Authorization Required' or 'No Prior Authorization Required').

How it's shownEach HCPCS/CPT line entry pairs the code with a short PA designation (examples throughout J‑code and Q‑code lists).

Actionable outcomeCheck the per‑line PA designation before billing; where 'Prior Authorization Required' is shown, obtain PA to avoid claim denial.

inv-106: Not therapeutically equivalent

DefinitionTable notes that certain manufacturer's product entries are not therapeutically equivalent to other J‑codes (explicit non‑equivalence alerts).

ExamplesDaptomycin (Baxter) entries and other manufacturer‑specific listings are repeatedly annotated as 'not therapeutically equivalent' in the excerpt.

ImplicationNon‑equivalence annotations affect substitution, PA evaluation, and coverage—use specified manufacturer mapping for determinations.

inv-107: Prior Authorization Required

DefinitionSimple status label indicating the code requires prior authorization before coverage/payment.

Common useApplied to many gene therapy, specialty and implant J‑codes in the table (e.g., J1411–J1414 and many J73xx entries).

Provider reminderObtain PA per payer instructions for any code line labeled 'Prior Authorization Required'.

inv-108: No Prior Authorization Required

DefinitionNo PA required designation for items handled under the Pharmacy Benefit or explicitly marked 'No Prior Authorization Required'.

ExamplesCertain pharmacy‑benefit mapped entries (e.g., J7515 and many J06xx ESRD oral agent mappings) are annotated as No Prior Authorization Required.

Billing effectWhen listed as No Prior Authorization Required (Pharmacy Benefit), claims may be processed without medical PA but follow pharmacy program rules.

inv-109: J-code prior authorization table

DefinitionTable format pairing HCPCS J‑codes with drug descriptions and a short prior authorization designation (e.g., 'No Prior Authorization Required' or 'Prior Authorization Required').

PurposeProvides per‑code guidance for PA need and maps each code to a product/brand and brief descriptor.

UseRefer to the specific J‑code line in the table for exact PA and product mapping when preparing authorizations or claims.

inv-110: J3590

DefinitionUnclassified code used for products not assigned a specific HCPCS J‑code (J3590).

Billing cautionWhen J3590 is used, verify the specific product and PA designation in the payer table to determine coverage and authorization needs.

inv-111: J7030-J7100

DefinitionRange of unclassified infusion codes (J7030–J7100) used for ESRD/dialysis fluids (normal saline/dextrose) and related infusions.

PA statusThese infusion/ESRD fluid codes are shown as No Prior Authorization Required in the excerpt (examples: J7030, J7042, J7060).

Usage noteUsed for billing common dialysis/infusion solutions; drugs and nursing visits may be billed separately as applicable.

inv-112: Prior authorization / ESRD labeling

DefinitionEntries annotate whether a HCPCS J‑code requires prior authorization, is assigned to the pharmacy benefit, and include brief drug/descriptive notes (ESRD labeling present).

ExamplesJ0604 annotated 'No Prior Authorization Required' for cinacalcet (ESRD on dialysis); J0602 annotated 'Prior Authorization Required = Pharmacy Benefit'.

Practical noteCheck both PA and benefit assignment fields on each line—some codes show combined flags (e.g., 'Prior Authorization Required = Pharmacy Benefit').

inv-113: Pharmacy Benefit

DefinitionIndicates the J‑code or drug is managed under the pharmacy benefit (may change PA rules or exclude medical PA).

ExamplesSeveral entries in the J75xx and J86xx ranges are marked 'Pharmacy Benefit' (e.g., J7515, J7516).

Billing implicationPharmacy Benefit assignment may require providers to follow pharmacy prior authorization or dispensing processes rather than medical PA workflows.

inv-114: Not Covered

DefinitionExplicit denial designation in the list meaning the payer will not cover that HCPCS code/formulation under the referenced benefit.

ExamplesSpecific entries shown as Not Covered include certain compounded inhalation solutions (e.g., J7632, J7634, J7638) and some CGM accessory codes (A9276–A9278).

Provider guidanceDo not bill or expect payment for codes marked Not Covered; discuss alternative covered therapies or formulary options with the payer or patient.

inv-115: Pharmacy Benefit

DefinitionPharmacy Benefit designation for listed entries (repeat confirmation across table segments).

ExampleMultiple entries across the document reiterate Pharmacy Benefit mapping for certain J‑codes and oral/infusible products.

Operational noteWhen 'Pharmacy Benefit' is shown, check the applicable pharmacy prior auth and dispensing rules before billing under the medical benefit.

inv-116: Prior Authorization status

DefinitionNo Prior Authorization Required / Prior Authorization Required indicates whether prior authorization is needed for the listed HCPCS J‑code or drug product.

UsageEach line in the HCPCS table uses this PA status field to guide provider action (examples across J060x, J157x, J28xx, etc.).

ActionAlways follow the per‑line PA status when preparing claims or requesting prior authorizations to avoid denials or incorrect routing.

inv-117: M0220 / M0221

DefinitionM0220 / M0221 refer to injection of tixagevimab and cilgavimab for pre‑exposure prophylaxis in specified patients (age and weight criteria noted).

PA statusThese M‑codes are shown as No Prior Authorization Required in the excerpt for the described use.

inv-118: M0249 / M0250

DefinitionM0249 / M0250 denote intravenous infusion of tocilizumab for hospitalized patients with COVID‑19 (first and second dose) including monitoring.

PopulationHospitalized adults and pediatric patients (>=2 years) receiving systemic corticosteroids and requiring supplemental oxygen or mechanical support.

PA statusThese M‑codes are shown as No Prior Authorization Required in the excerpt for the specified inpatient COVID‑19 indication.

inv-119: pre-exposure prophylaxis

DefinitionPre‑exposure prophylaxis: administration of specified monoclonal antibodies to prevent infection in high‑risk individuals prior to exposure.

Example codesM0220/M0221 and Q0220/Q0221 range map to tixagevimab/cilgavimab (Evusheld) for pre‑exposure prophylaxis as annotated in the table.

DocumentationEntries include indication text and monitoring requirements in the table (see M0221 and related Q‑code lines).

inv-120: Prior Authorization Required

DefinitionAnnotation indicating whether prior authorization is required for billing/coverage of the listed injectable (map field 'Prior Authorization Required').

ExampleMultiple Q‑ and M‑codes show 'Prior Authorization Required = No Prior Authorization Required' variants; check per‑line mapping.

Provider actionFollow the per‑code Prior Authorization Required field when submitting authorization requests or claims.

inv-121: Home infusion therapy per diem

DefinitionHome infusion therapy per diem: per‑day billing for home infusion services including administrative and professional pharmacy services; drugs and nursing billed separately.

Example codesS5501, S5502 and S9325–S9331 are used to bill home infusion per‑diem services with PA status indicated per line.

Billing notePer‑diem codes cover administrative/pharmacy services; actual drug and nursing visits are coded and billed separately as noted in the table.

inv-122: Insulin cartridge/pen

DefinitionInsulin cartridges and disposable insulin delivery pens are listed with unit sizes and prior authorization statuses in the table.

ExamplesS5566 (insulin cartridge 300 units), S5570 and S5571 (insulin disposable pen sizes 1.5 ml and 3 ml) are shown with No Prior Authorization Required in the excerpt.

Operational noteVerify unit size and PA mapping on the exact S‑code line when billing insulin supplies/pen cartridges.

inv-123: No Prior Authorization Required

DefinitionNo Prior Authorization Required — annotation indicating the listed code does not require prior authorization per this segment.

ExamplesDocument includes many 'No Prior Authorization Required' entries (e.g., J0601–J0608, J0615, S5570, 90382, 91323).

ActionProviders may proceed to bill without PA for codes explicitly annotated No Prior Authorization Required in the payer's table.

inv-124: Prior Authorization Required

DefinitionPrior Authorization Required — annotation indicating the listed code requires prior authorization per this segment.

ExamplesMultiple entries such as J9054, J9161, J7169 and many Q‑codes are marked Prior Authorization Required in the excerpts.

Provider implicationObtain and document PA approval prior to service to reduce denials for codes with this annotation.

inv-125: No Prior Authorization Required

DefinitionNo Prior Authorization Required — simple status note repeated across table segments indicating no PA needed for the listed code.

ExamplesSeen across vaccine administration, ESRD infusion, and select J‑code entries (e.g., 0054A[4], 0064A[4], J0601).

GuidanceConfirm the specific line in the payer table; if listed as No Prior Authorization Required, submit claim without PA.

inv-126: Prior Authorization Required

DefinitionPrior Authorization Required — annotation indicating PA is required for the listed code in this segment of the payer's mapping.

ExamplesNumerous high‑cost J‑codes, coagulation factors, and specialized biosimilars are flagged as Prior Authorization Required in the tables.

RecommendationSubmit PA requests with supporting clinical documentation per payer requirements before performing billed services for these codes.

inv-127: Not Covered

DefinitionNot Covered — annotation indicating the listed code/product is not covered by the payer for the referenced formulation or use.

ExamplesCGM transmitter/receiver accessories (A9277, A9278) and several compounded inhalation solutions (J7632–J7643 groups) are explicitly listed Not Covered.

ConsequenceClaims for Not Covered items will be denied; providers should identify covered alternatives or coordinate patient financial responsibility discussions.