Medical Benefit Precertification List (medical-administered drugs)
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
This document is an administrative Precertification List that identifies medical benefit drugs and their associated HCPCS codes which require prior authorization through the Medical Benefit Drug Review program for commercial plan members. It functions as an administrative precertification reference for providers and billing staff and does not set forth clinical coverage criteria, indications, dosing, or medical necessity rules in this section.
Drug / HCPCS Coding Lists
Provider Actions & Requirements
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/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.
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.
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.
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.
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