ModifiedEmblemHealthPolicy N/A

Pharmacy Medical Preauthorization List

Lists medical and pharmacy drugs subject to EmblemHealth preauthorization and specialty pharmacy requirements for outpatient settings; applies to EmblemHealth Commercial, Medicaid, and Medicare members (with some plan-specific exclusions).

Policy Summary

PayerEmblemHealth

PolicyPharmacy Medical Preauthorization List

Policy CodePolicy N/A

Change TypeMaterial changes to codes and preauthorization requirements

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionUse ePA or contact the listed preauthorization phone/fax to request prior authorization; ePA is available and encouraged.

SourceLink

POLICY UPDATE CHANGES

Preauthorization requirement removed for two drugs effective 7/01/2025: J9341 and J9342 (Tepylute).

Multiple new codes and drugs were added with various effective dates throughout 2024–2025 (examples include new codes J9276, J9341, J9342, J1326, J7356).

Several codes were deleted effective various dates (examples: J9340, C9302, C9303, C9173).

12/31/2025DOS applicability

Commercial/Medicaid/MedicareLines of business

multipleNew/deleted codes

YES/NOSpecialty pharmacy flag

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Coverage and Preauthorization Criteria

inv-01: Coverage and preauthorization criteria — operational rules and coverage stance for listed drugs

Covered when the following operational rules are met:

Policy applies to EmblemHealth Commercial, Medicaid, and Medicare; excludes City of New York PPO; plan-specific exceptions may apply

Source: policy applicability statement

Specialty Pharmacy Requirements Drug List indicates per-drug 'YES' or 'NO' whether specialty pharmacy sourcing is required for outpatient places of service (outpatient hospital, physician office, member home, ambulatory infusion); Home Infusion providers are excluded

Specialty pharmacy sourcing requirement effective July 14, 2025

The Pharmacy Medical table lists HCPCS/J/C/Q codes, generic drug names, and a 'Specialty Pharmacy Requirements (Yes/No)' flag to guide prior-authorization routing

Drug-level entries include code, name, and specialty pharmacy flag

Electronic prior authorization (ePA) is available and encouraged for prior authorization submissions

Operational contact and ePA availability provided

inv-02: Coverage stance in extract — drug/code list with specialty pharmacy indicators

This extract designates drugs with billing codes and specialty pharmacy requirement flags (no clinical medical necessity criteria included in these excerpts).

Each line in the extract maps a drug to one or more billing codes and a 'Specialty Pharmacy Requirements (Yes/No)' indicator

Examples: Avtozma (Actemra biosimilar) marked NO; Beqvez entries with mixed flags

New and deleted code notices may be present alongside drug entries (effective dates shown)

Examples: Axtle new code 1/1/2025; Barhemsys new code 1/01/2024

inv-03: Coverage stance in excerpt — code mappings and specialty pharmacy flags (no clinical criteria)

Code mappings and specialty pharmacy requirement indicators are provided in this excerpt; clinical coverage criteria and member eligibility rules are not included here.

Entries show HCPCS/J-codes (including placeholders such as J9999 or J3590) with Specialty Pharmacy Requirements = YES or NO per product

Examples: Elrexfio (J9999) NO; Entyvio (J3380) YES; Eylea (J0178) YES

Some lines include 'New code' or 'Deleted code' annotations with effective dates

Example: Emblaveo J0458 New Code effective 10/01/2025

inv-04: Drug-code listing and specialty pharmacy flags

Drug-to-code listings with specialty pharmacy requirement flags (clinical criteria not included in these chunks).

Each drug entry lists one or more billing codes and the Specialty Pharmacy Requirements flag (Yes/No)

Examples within these chunks include Izervay (J3490) NO; Jelmyto (J9281) NO; Jivi (J7208) NO

Examples

Izervay, Code = new 1/01/2024 (J3490), Specialty Pharmacy Requirements = NO
Jubbonti, Code = Q5136 (New Code), Specialty Pharmacy Requirements = NO
Kanuma, Code = J2840*, Specialty Pharmacy Requirements = YES

inv-05: Coverage exceptions and Medicare-specific notes

Coverage exceptions and Medicare-specific notes present in the list:

Spravato (S0013) is marked 'Not covered for Medicare'

Chunk indicates S0013 Not covered for Medicare

Spravato G2082 and G2083 entries are designated 'Medicare only' for the associated office/outpatient visit codes

Chunk specifies Medicare-only status for G2082/G2083

inv-06: Specialty pharmacy requirement entries — flags indicating specialty pharmacy requirement per product

Products in the list are tagged to indicate whether specialty pharmacy handling/enrollment is required.

Specialty Pharmacy Requirements column uses 'YES' or 'NO' to indicate whether the product must be sourced through a specialty pharmacy or subject to special prior-authorization processes

Examples: Pombiliti YES; Privigen YES; Roctavian YES

Operational implication

If 'YES', prior authorization routing and fulfillment must follow the Specialty Pharmacy Requirements Drug List policy (effective 7/14/2025)
If 'NO', standard prior authorization and fulfillment processes apply

inv-07: Entries and coverage flags — drug entries with codes, descriptions, specialty pharmacy flags and revision notes

Selected drug entries with billing codes and specialty pharmacy flags; revision history notes affecting preauthorization or code status are recorded elsewhere in the document.

J3240 — Thyrogen — Specialty Pharmacy Requirements = NO

Chunk 91 lists Thyrogen J3240 with NO

J9341 — Tepylute — Specialty Pharmacy Requirements = NO (New Code effective 7/01/2025)

Chunk 90 shows Tepylute J9341 new code 7/01/2025

J9342 — Tepylute (NOS) — Specialty Pharmacy Requirements = NO (New Code effective 7/01/2025)

Chunk 90 shows Tepylute J9342 new code 7/01/2025

J1303 — Ultomiris — Specialty Pharmacy Requirements = YES

Chunk 96 lists Ultomiris J1303 with YES

inv-08: Revision-driven coverage notes — revisions that affect coverage workflows and authorization requirements

Revision notes that impact coverage workflows and authorization requirements:

The criteria in this list apply to dates of service on or before 12/31/2025

Revision History DOS applicability statement

Preauthorization requirement removed for J9341 and J9342 (Tepylute) effective 7/01/2025

Revision entry dated 3/23/2026 documents removal effective 7/01/2025

Specialty Pharmacy Requirements column was added to the list (update effective 7/14/2025) to indicate 'YES' when specialty pharmacy requirements apply

Revision notes indicate column addition and associated policy update

Coding, HCPCS/J/Q Codes and Status

Examples from code listHCPCS

Q2055	Abecma
J9264	Abraxane (paclitaxel protein-bound particles), 1 mg

Examples of new/changed codes and biosimilarsHCPCS | mixed

Q5158	Bomyntra/Conexxence - Prolia/Xgeva Biosimilar, denosumab-bnht, biosimilar, 1 mg
J9037	Blincyto, blinatumomab, 1 microgram
J9039	Blincyto* (alternate starred code)

New codes and use of J3590HCPCS | mixed

J0458	Emblaveo, aztreonam/avibactam
J3590	Placeholder/new drug code used for multiple drug entries (e.g., Cosentyx, Daxxify, Cimerli)

sample HCPCS/Q-codes from excerptHCPCS | NDC | mixed

J9999	placeholder/unclassified HCPCS used for Elrexfio and Emrelis in this list
J9269	Elzonris (tagraxofusp-erzs)
J1434	Emend (fosaprepitant)
J9358	Enhertu (fam-trastuzumab deruxtecan-nxki)
J1302	Enjaymo (sutimlimab-jome)
J3380	Entyvio (vedolizumab)
Q5151	Epsyqli (eculizumab biosimilar)
J9055	Erbitux (cetuximab)
J0178	Eylea (aflibercept)
J1428	Exondys 51 (eteplirsen)

1–10 of 13

1/2

Representative HCPCS/J codes in windowHCPCS

J9281	Jelmyto, Mitomycin pyelocalyceal instillation, 1 mg
J9272	Jemperli (dostarlimab-gxly), 100 mg
J3590	Multiple entries use J3590 as a placeholder for various injections (e.g., Kisunla, Leqembi, Lenmeldy)

Selected J-codes in extractHCPCS

J2440	Injection, papaverine HCl, up to 60 mg
J9045	Injection, carboplatin, 50 mg
J0606	Injection, etelcalcetide, 0.1 mg

Biosimilars and biologicsHCPCS

Q5139	Injection, eculizumab-aeeb (biosimilar), 10 mg (new/deleted code notes present)
J3358	Ustekinumab, IV injection, 1 mg (Stelara*)

Selected new or notable codes in this excerptHCPCS

J9341	Tepylute, Injection, thiotepa (Tepylute), 1 mg
J9342	Tepylute, Injection, thiotepa, not otherwise specified, 1 mg
J9276	Ziihera, Injection, zanidatamab-hrii, 2 mg
J1326	Vyloy, Injection, zolbetuximab-clzb, 2 mg

Examples of recently added/changed codes (non-exhaustive)mixed

J9341	Tepylute (preauth removed effective 7/01/2025)
J9342	Tepylute (preauth removed effective 7/01/2025)
C9305	Emrelis (added effective 10/01/2025)
J0458	Emblaveo (added effective 10/01/2025)

Deleted / Added code effective dates

Example code added then deletedJ9259 — New code effective 01/01/2024; Deleted Code effective 01/01/2025

Other new code effective datesMultiple 'New Code effective' entries listed throughout (examples in list include J9272 effective 01/01/2024; J3590 entries noted 2024–2025)

Deleted code examplesSeveral 'Deleted Code effective' entries noted (examples: Marqibo deleted 07/01/2024; Eylea HD C9161 deleted 04/01/2024)

CAR-T dose description threshold

CAR-T dose description

How to Request Authorization and Provider Requirements

Prior Authorization

Preauthorization Required

Contact EmblemHealth to request preauthorization for pharmacy and medical drugs. ePA is available. Use the numbers below based on benefit type and request type.

Commercial Pharmacy fax/electronic: 877-251-5896
Commercial Medical fax/electronic: 866-896-1209
Medicare Pharmacy fax/electronic: 877-251-5896
Medicare Medical fax/electronic: 866-896-1209
Medicaid Pharmacy fax/electronic: 877-251-5896
Medicaid Medical fax/electronic: 866-896-1209
Commercial Pharmacy phone (24/7/365): 844-516-3324
Commercial Medical phone (Mon–Fri 8am–7pm): 877-681-9866
Medicare Pharmacy phone (24/7/365): 877-920-1470
Medicare Medical phone (Mon–Fri 8am–7pm): 877-681-9866
Medicaid Pharmacy phone (24/7/365): 888-281-5539
Medicaid Medical phone (Mon–Fri 8am–7pm): 877-681-9866
Partner for traditional pharmacy: ESI

Definitions and Notes

Pharmacy Medical Preauthorization List

DefinitionPharmacy Medical Preauthorization List: a cumulative table indicating for each drug whether Specialty Pharmacy Requirements apply and listing applicable HCPCS/J-codes and notes

PurposeUsed to identify drugs requiring preauthorization and to show per-drug specialty pharmacy handling (YES/NO) to guide authorization routing

Coverage scopeApplies to outpatient administered drugs with associated codes; includes new/deleted code notes and plan-specific coverage annotations

Evolent scope / out-of-scope categories

Evolent scopeEvolent (formerly New Century Health) handles preauthorization for oncology-related chemotherapeutic drugs and supportive agents administered in physician office, outpatient, or ambulatory settings for a subset of members

Age and member scope note

Revision History and Policy Changes

2026-03-23revisionLatest

Preauthorization requirement removed for two drugs (J9341 and J9342 - Tepylute) effective 2025-07-01; revision history entry recorded 3/23/2026.

2025-10-01code_additions

Added 14 new codes effective 10/01/2025 (examples: C9305, C9306, J0458, J0614, J1809, J3402, J3403, J9011, Q5154–Q5159) and one revised description (J9072); two codes deleted (C9174, C9175).

2025-07-01

Policy Summary

PayerEmblemHealth

PolicyPharmacy Medical Preauthorization List

Policy CodePolicy N/A

Change TypeMaterial changes to codes and preauthorization requirements

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionUse ePA or contact the listed preauthorization phone/fax to request prior authorization; ePA is available and encouraged.

SourceLink

On This Page

Carvykti (Q2056) described as 'up to 100 million autologous ... directed CAR-positive T cells... per therapeutic dose'

Includes leukapheresis and dose preparationEntry specifies 'including leukapheresis and dose preparation procedures' as part of the per therapeutic dose unit

Specialty pharmacy flag for CAR-TCarvykti Specialty Pharmacy Requirements = NO

Criteria dates of service applicability

DOS applicability statementThe criteria detailed in this list apply to dates of service (DOS) on or before 12/31/2025

Revision history confirms DOS noteRevision History entries reiterate that criteria apply through DOS 12/31/2025

Effective date contextDocument header notes policies are current as of publication date and subject to updates communicated via provider notices

Partner for medical drug, non-chemo: Care Continuum / ESI

Billing Rule

Specialty Pharmacy Sourcing Requirement

Certain outpatient drugs must be obtained from indicated specialty pharmacies when the 'Specialty Pharmacy Requirements (Yes/No)' flag is YES. See the Specialty Pharmacy Requirements Drug List Reimbursement Policy for required pharmacies. This requirement applies to outpatient places of service (outpatient hospital, physician office, member home, ambulatory infusion) but does not apply to Home Infusion providers. The Pharmacy Medical table below indicates YES where specialty pharmacy sourcing is required.

Note

Drug and Code Listing — Specialty Pharmacy Requirement (Yes/No)

The table below lists drugs, codes, and whether specialty pharmacy requirements apply (Yes/No). This consolidated list preserves entries from the Pharmacy Medical Preauthorization List as presented (examples shown).

Note

Code-to-Drug Mapping Examples (A–C)

Examples (drug — code — specialty pharmacy requirement): - Avtozma — (Q5156 / J3490) — NO - Axtle — J9292 — NO - Azedra — A9590 — NO - Barhemsys — J0184 / J3490 — NO - Bavencio — J9023 — NO - Baxdela — C9462 — NO - Bebulin / Profilnine — J7194 — NO - Botox — J0585 — NO - Breyanzi — Q2054 — NO - Brineura — J0567 — YES - Briumvi — J2329 — YES - Busulfex — J0594 — NO - Byooviz — Q5124 — YES - Cabenuva — J0741 — NO - Cablivi — C9047 — NO - Camcevi — J1952 — (see list)

Note

Code-to-Drug Mapping Examples (E)

Examples (drug — code — specialty pharmacy requirement): - Elrexfio — J9999 — NO - Elzonris — J9269 — NO - Emblaveo — J0458 — NO - Emend — J1434 / J1453 / J1456 — NO - Empaveli — C9151 / J3490 — NO - Emrelis — J9999 / C9305 — NO - Encelto — J3403 / J3590 — NO - Enhertu — J9358 — NO - Enjaymo — J1302 — YES - Entyvio — J3380 — YES - Enzeevu — Q5149 — NO - Epkinly — J9321 — (see list)

Note

Code-to-Drug Mapping Examples (I–J)

Examples (drug — code — specialty pharmacy requirement): - Izervay — J3490 — NO - Jelmyto — J9281 — NO - Jemperli — J9272 — NO - Jesduvroq — J0889 — NO - Jetrea — J7316 — NO - Jevtana — J9043 / J9064 — NO - Jivi — J7208 — (see list)

Note

Code-to-Drug Mapping Examples (P)

Examples (drug — code — specialty pharmacy requirement): - Papacon / PAPAVERINE HCL / Para-Time S.R. / Pavabid Plateau / Pavagen — J2440 — NO - Paraplatin — J9045 — NO - Parsabiv — J0606 — NO - Pavblu — J3590 / Q5147 — (Specialty Pharmacy flag in list)

Note

Code-to-Drug Mapping Examples (S–T)

Examples (drug — code — specialty pharmacy requirement; special Medicare notes where present): - Spomyv/Xbryk — Q5159 — NO - Spravato — S0013 / G2082 / G2083 — NO (S0013 Not covered for Medicare; G2082/G2083 Medicare only) - Temodar Injection — J9328 — NO - Tepadina/Thioplex — J9340 — NO (deleted code noted) - Tepezza — J3241 — YES - Tepylute — J9341 / J9342 — NO (preauthorization removed effective 7/01/2025)

Note

Code-to-Drug Mapping Examples (T–V)

Examples (drug — code — specialty pharmacy requirement): - Thyrogen — J3240 — NO - Ultomiris — J1303 — YES - Unloxcyt — J9275 — NO - Uplizna — J1823 — YES - Vabysmo — J2777 — NO - Vimizim — J1322 — YES - Vpriv — J3385 — YES - Vyalev — J7799 / J7356 — NO - Vyepti — J3032 — YES - Vyjuvek — J3401 / J3590 — J3401 flagged YES; J3590 flagged NO (per list)

Note

Code-to-Drug Mapping Examples (X–Y)

Examples (drug — code — specialty pharmacy requirement): - Xembify — J1558 — YES - Xenpozyme — J0218 — YES - Xeomin — J0588 — NO - Xiaflex — J0775 — YES - Xofigo — A9606 — NO - Xolair — J2357 — YES - Xyntha — J7185 — NO - Yervoy — J9228 — NO - Yesafili — Q5155 — NO - Yescarta — Q2041 — NO - Yuflyma — Q5141 — (see list)

Documentation Required

Operational Notes

Notes and operational items: - The Specialty Pharmacy Requirements column was added effective 7/14/2025 and indicates YES where specialty pharmacy sourcing is required. - Preauthorization requirement for J9341 and J9342 (Tepylute) was removed effective 7/01/2025 per revision history; verify current DOS applicability. - This list is cumulative and updated periodically; providers should reference the most recent Revision History and Specialty Pharmacy Requirements Drug List Reimbursement Policy for required pharmacies and any code changes.

Note: This Evolent requirement does not apply to members under 18 years of age

Out-of-scope categoriesLists specific out-of-scope categories including bone marrow transplants, clinical trials, home health, inpatient chemotherapy, ESRD patients, hemophilia drugs, and equipment requests

Per therapeutic dose (definition)

Meaning'Per therapeutic dose' denotes billing the code unit for a full therapeutic dose instance for gene/cell therapies (example: Carvykti entry)

Example inclusionCarvykti entry specifies dose unit includes leukapheresis and dose preparation procedures per therapeutic dose

Applies to gene/cell therapiesUsed for CAR-T and similar autologous therapies where dosing is described as a therapeutic dose rather than per mg or per cell beyond the stated threshold

Specialty Pharmacy Requirements (flag)

Flag definitionSpecialty Pharmacy Requirements column indicates whether specialty pharmacy handling/authorization is required for the listed product (Yes or No)

Routing useThe Yes/No flag guides prior authorization routing and fulfillment pathway for outpatient drugs

ExamplesEntries show both YES and NO values (examples: Thyrogen J3240 = YES; Izervay J3490 = NO)

Specialty Pharmacy Requirements — alternate examples

Alternate phrasingSpecialty Pharmacy Requirements (Yes/No) flag denotes whether the product requires fulfillment through a specialty pharmacy or special prior authorization processes

Operational impactIndicates if products are subject to specialty pharmacy sourcing and enrollment requirements effective per policy updates

Examples in listMultiple entries in the list include this flag (e.g., Ultomiris J1303 = YES; Vimizim J1322 = YES)

Code change notes (New / Deleted)

New/Deleted code note'New Code' or 'Deleted Code' entries are used to indicate coding changes and are listed with effective dates alongside the product entry

Revision contextRevision history documents numerous code additions and deletions with effective dates (examples: additions on 7/01/2025 and 10/01/2025; deletions on 4/01/2025)

Example entryAbraxane J9259 noted as New code effective 01/01/2024 then 'Deleted Code effective 01/01/2025' in the list

Specialty Pharmacy Requirements — additional note

Yes/No indicator meaningIndicates whether the product requires fulfillment through a specialty pharmacy or special prior authorization processes (YES = specialty pharmacy requirements apply)

Guides fulfillmentUsed to determine routing for prior authorization and specialty dispensing versus standard pharmacy channels

Present throughout listColumn appears across many product entries (examples: Papacon J2440 = NO; Jivi J7208 = NO; Ultomiris J1303 = YES)

Code status notes (New Code / Deleted Code)

New Code entries with datesTepylute codes J9341 and J9342 listed as New Code effective 07/01/2025 (and noted in revision history)

Deleted Code examplesMarqibo noted as 'Deleted Code effective 07/01/2024' and other deletions listed in revision history

Revision history sourceRevision History section enumerates code status changes and effective dates across multiple revisions

Specialty Pharmacy Requirements — reference

Specialty Pharmacy = YES meaningA 'YES' in Specialty Pharmacy Requirements indicates the product is subject to specialty pharmacy handling and associated authorization processes

Examples of YES entriesUltomiris (J1303) = YES; Luxturna (J3398) = YES; Vimizim (J1322) = YES

Examples of NO entriesMany products marked NO indicate standard fulfillment (examples: Papacon J2440 = NO; Izervay J3490 = NO)

Medicare coverage status definition

Limited Medicare coverage notation'Not covered for Medicare' or 'Medicare only' annotations indicate plan-specific Medicare coverage limitations for the listed code/product (example: Spravato S0013 = Not covered for Medicare; G2082/G2083 = Medicare only)

Where notedThese Medicare-specific coverage notes appear alongside product/code entries to clarify coverage stance for Medicare members

Impact on routingSuch notations affect claim adjudication and prior authorization expectations for Medicare plan members

Dates of Service applicability

DOS applicabilityCriteria detailed in this list apply to dates of service (DOS) on or before 12/31/2025

Revision confirmationRevision History reiterates the DOS applicability statement across entries and revisions

Applies to listed criteriaAll drug-level criteria and specialty pharmacy flags in this list are tied to the DOS applicability date stated

Specialty Pharmacy Requirements — supplementary examples

Supplementary flag examplesThe Specialty Pharmacy Requirements column is populated with YES/NO across many entries — examples: Thyrogen J3240 = YES; Ultomiris J1303 = YES; Papacon J2440 = NO

Policy update notedSpecialty Pharmacy Requirements column was added as part of a policy update effective 07/14/2025 to indicate YES when requirements apply

Operational useFlags are used to direct providers to specified specialty pharmacy fulfillment or standard channels

Specialty Pharmacy Requirements column (indicator added)

Column additionA 'Specialty Pharmacy Requirements' column was added to the list (update effective 07/14/2025) to denote if specialty pharmacy requirements apply to a drug code

FunctionServes as an indicator to mark 'YES' for products requiring specialty pharmacy sourcing/authorization

Present across entriesColumn appears across many product entries including those added or revised in 2024–2025 updates

code_additions_deletions

Added 17 new codes effective 07/01/2025 (examples include C9174, C9175, J1326) and noted deletions and replacements in the 7/01/2025 update (see list).

2025-04-01policy_update

Specialty Pharmacy Requirements column added to the list (indicates 'YES' if specialty pharmacy requirements apply) as part of the 4/2025 update documenting the new Specialty Pharmacy Requirements Drug List criteria effective 07/14/2025.

2025-07-01preauthorization_removed

Preauthorization requirement removed for J9341 and J9342 (Tepylute) effective 07/01/2025, recorded in the revision history and noted again 03/23/2026.

2025-07-14operational_change

Specialty Pharmacy Requirements Drug List reimbursement policy criteria implemented; 'Specialty Pharmacy Requirements' column added to indicate when specialty pharmacy sourcing applies (noted in April 2025 update, effective 07/14/2025).

2025-01-01dos_applicability

Criteria in this list apply to dates of service on or before 12/31/2025 (document-wide applicability statement recorded in the revision history).