CurrentEmpire BluecrossPolicy N/A

Medical Benefit Precertification List (medical-administered drugs)

List of medical benefit drugs that require precertification for commercial plan members under Empire Bluecross's Medical Benefit Drug Review program; intended for providers and billing staff administering or billing these drugs.

Policy Summary

PayerEmpire Bluecross

PolicyMedical Benefit Precertification List (medical-administered drugs)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest precertification via the Medical Benefit Drug Review program for any listed drug prior to administration or billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~400listed drug entries (approx.)

HCPCS codes includedHCPCS mapping

Commercial plansplan applicability

multiple languageslanguage assistance

TTY: 711TTY/TDD

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Drug / HCPCS Coding Lists

Sample listed HCPCS codes (example entries)HCPCS

Q5145	Abrilada
J3262	Actemra
J0801	Acthar
J0791	Adakveo
C9399	Adbry (also J3490 J3590 listed)

Additional example HCPCS codes (from same sample block)HCPCS

J0172	Aduhelm
J7192	Advate
J7207	Adynovate
J7171	Adzynma
J7210	Afstyla

Additional HCPCS codes (enumerated across document)HCPCS

C9399	Amjevita (also J3590 listed)
J1426	Amondys 45
J0225	Amvuttra
J3380	Entyvio IV
J0178	Eylea
J2506	Neulasta
J2350	Ocrevus
J1745	Remicade
J1628	Tremfya
J2778	Lucentis

1–10 of 64

1/7

Later-document HCPCS codes (selected additional entries)HCPCS

J0897	Prolia
Q9997	Pyzchiva IV
Q9996	Pyzchiva SC
J1304	Qalsody
J1301	Radicava
J1745	Remicade
J1628	Tremfya
J2778	Lucentis
J2357	Xolair
J1558	Xembify

1–10 of 19

1/2

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Precertification is required for the medical benefit drugs listed in this policy. Providers must request prior authorization through Empire BlueCross' Medical Benefit Drug Review program before administering any listed medical benefit drug.

Request prior authorization via the Medical Benefit Drug Review program prior to drug administration.
Affected drugs include, but are not limited to: Abrilada (Q5145); Actemra (J3262); Acthar (J0801); Adakveo (J0791); Aduhelm (J0172); Amjevita (C9399, J3590); Avastin (C9257, J9035); Botox (J0585); and others listed in the Medical Benefit Precertification List.

Denial Risk

Denial/Coverage Risk if Not Precertified

Failure to obtain the required precertification may result in claim denial or coverage delay. Providers should verify authorization prior to service to avoid reimbursement risk.

Denial/coverage risk if prior authorization is not obtained for listed medical benefit drugs.

Documentation Required

Precertification Process and Documentation

Documentation of the precertification request and approval should be maintained in the patient record. Follow the Medical Benefit Drug Review program instructions when submitting clinical information.

Document authorization number and date in patient chart.
Retain copies of submitted clinical rationale and prior authorization responses.

Note

Provider Actions

Providers must take action to request precertification via the Medical Benefit Drug Review program prior to administration of listed drugs. This is a provider responsibility — absence of authorization may lead to nonpayment.

Contact Medical Benefit Drug Review before administering any listed medical benefit drug.
Verify member eligibility and benefits and obtain authorization confirmation.

Note

Language Assistance & Nondiscrimination Rights

Empire BlueCross provides free language assistance and nondiscrimination protections. Members have the right to receive information and assistance in their preferred language at no cost, and TTY/TDD access is available at 711.

Free language assistance services available; call the Member Services number on the member's ID card. (TTY/TDD: 711).
If a member believes they were discriminated against, they may file a complaint with the Compliance Coordinator (Compliance Coordinator, P.O. Box 27401, 23279) or with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue SW, Room 509F, Washington, D.C. 20201; 1-800-368-1019 (TDD: 1-800-537-7697).
Complaint forms: https://www.hhs.gov/ocr/office/file/index.html

Background & Definitions

Background: The list is limited to administrative precertification requirements for medical-administered drugs; it does not provide clinical coverage criteria or clinical indications. Providers must use the Medical Benefit Drug Review program to request precertification for any drugs listed prior to administration or billing. Clinical determinations and medical necessity criteria are not included in this portion of the document.

Medical Benefit Drug Review program — definition/key facts

Program nameMedical Benefit Drug Review program

PurposeProviders must obtain precertification (prior authorization) for medical-administered drugs listed in this document prior to administration and billing for commercial plan members

ScopeApplies to medical benefit drugs and associated HCPCS codes listed in the Medical Benefit Precertification List for commercial plan members

Consequence of noncomplianceFailure to obtain precertification may result in denial of coverage or claims being unpaid for commercial plan members

Action required from providersSubmit precertification requests through the Medical Benefit Drug Review program before drug administration/billing

Nondiscrimination — rights and complaint process

Nondiscrimination statementThe plan follows federal civil rights laws and does not discriminate based on race, color, national origin, sex, age or disability.

Language assistanceFree language assistance services (interpreters and written translations) are available at no cost to members whose primary language isn’t English.

Accessibility servicesFree aids and services are offered for people with disabilities.

How to file a complaint (grievance)File with Compliance Coordinator in writing at P.O. Box 27401, 23279; or file with HHS OCR at 200 Independence Avenue SW, Room 509F, Washington, D.C. 20201; call 1-800-368-1019 (TDD: 1-800-537-7697) or file online.

Links to complaint formsComplaint forms available at http://www.hhs.gov/ocr/office/file/index.html