Prior Authorization Routing

Prior authorizations for oncology and hematology drugs and radiation oncology services for Florida Blue Medicare Advantage members will be routed to New Century Health beginning Jan 1, 2021. Providers must submit prior authorization requests to New Century Health for the drugs listed in Appendix A and for radiation oncology services and CPT/G-codes flagged as requiring prior authorization in Appendix B. Authorizations previously managed by Magellan Rx Management will be transitioned to New Century Health per the Appendix A key and code highlighting rules.

• Effective date: Jan 1, 2021
• Drug prior authorizations: Appendix A (HCPCS/J-codes) — managed by New Century Health unless key indicates otherwise
• Radiation oncology prior authorization and utilization management: Appendix B (CPT and select G-codes) — managed by New Century Health

Denial Risk for Missing Prior Authorization

Services and drugs that require prior authorization but do not have an approved prior authorization on file beginning Jan 1, 2021 are at risk of denial. Providers are responsible for obtaining prior authorization before rendering the service or submitting the claim to avoid payment denial.

• Missing prior authorization for listed Appendix A drugs or Appendix B CPT/G-codes may result in claim denial
• Ensure authorization is obtained from New Century Health prior to treatment start or claim submission

Drug Prior Authorization (Appendix A)

Drug prior authorizations listed in Appendix A (HCPCS / J‑codes) must be requested and will be managed through New Century Health unless the Appendix A key indicates continued management by Magellan Rx Management or use outside oncology/hematology indications. Providers should reference Appendix A for the complete list of HCPCS/J‑codes requiring prior authorization and follow the Key for any exceptions.

• Appendix A lists affected HCPCS / J‑codes (e.g., J9227, J9228, J9229, J9230, J9245, J9246, etc.)
• Appendix A Key: Red highlight = New Century Health manages prior authorization; Green highlight = prior auth required only for oncology/hematology indications; Orange highlight = dual‑indication drugs may remain with Magellan Rx Management for non‑oncology uses

Per‑Code Prior Authorization Flags

Appendix B lists individual CPT and G‑codes with per‑code prior authorization flags. Each listed code indicates whether prior authorization review by New Century Health is required (Prior Auth = YES) or not required (Prior Auth = NO). Providers must consult the per‑code flags in Appendix B when determining whether to submit a prior authorization request.

• Per‑code flags appear in Appendix B beside each CPT or G‑code entry
• Use the Appendix B flag to determine if a New Century Health review/prior authorization is required

Codes Flagged PRIOR AUTH = YES

The following Appendix B CPT/G‑codes are explicitly flagged PRIOR AUTH = YES and require review/authorization by New Century Health prior to service delivery. This includes numerous radiation therapy planning, simulation, brachytherapy, proton therapy, IMRT/IMPT delivery, stereotactic radiosurgery, and certain guidance/localization codes.

• Examples of PRIOR AUTH = YES codes (non‑exhaustive): 19294, 19296, 19297, 19298, 20555, 32701, 41019, 43499, 47999, 55860, 55862, 55865, 55875, 55899, 55920, 57155, 57156, 58346, 77011, 77014, 77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77299, 77300, 77372, 77373, 77385, 77386, 77387, 77499, 77520, 77522, 77523, 77525, 77750, 77761, 77789, 77790, 77799, G0339, G0340, G6001, G6003, G6013, G6014, G6015, G6017
• Providers must obtain review/authorization from New Century Health for these codes prior to treatment

Codes Flagged PRIOR AUTH = NO

The following Appendix B CPT/G‑codes are explicitly flagged PRIOR AUTH = NO and do not require prior authorization review by New Century Health. These include many E/M codes, chemotherapy administration codes, infusion/hydration codes, blood draw and procedural support codes, and other supportive services.

• Examples of PRIOR AUTH = NO codes (non‑exhaustive): 36415, 36416, 36591, 36592, 36593, 38220, 38221, 38222, 85025, 85027, 96360–96379 series, 96401–96417 series, 96420–96425 series, 96521–96523, 96542, 96549, 99195, 99201–99205, 99211–99215, 99218–99226, 99231–99236, 99238–99239, 99291–99292, 99354–99360, 99406–99407, 99408–99409, 99411–99412, 99429, 99441–99443, 96423, 96425, 96440, 96446, 96450, 96521–96523
• Do not submit prior authorization requests to New Century Health for codes flagged PRIOR AUTH = NO

Prior Authorization Requirement for Select G‑Codes

Select G‑codes for radiation treatment delivery and image‑guided stereotactic radiosurgery are specifically listed in Appendix B and require prior authorization review by New Century Health. Examples include G0339 and G0340 for robotic linear accelerator‑based stereotactic radiosurgery, and multiple G60xx/G601x series codes describing radiation treatment delivery variations which are flagged PRIOR AUTH = YES.

• G0339, G0340 — image‑guided robotic linear accelerator‑based SRS (Prior Auth = YES)
• G6001, G6003, G6013, G6014, G6015, G6017 — various radiation treatment delivery and tracking G‑codes (Prior Auth = YES)
• Consult Appendix B to confirm the specific G‑code and prior authorization requirement before scheduling treatment