Member's products and coverage vary based upon the policy type and benefits. All services must meet the definition of medical necessity as outlined in the Member's benefit contract. Select benefit types enforce prior authorization to ensure the services align with the medical necessity criteria before the services are rendered, while other benefits verify the medical necessity criteria through post-service or concurrent review.

For products that require a prior authorization, failure to obtain an authorization prior to the service being rendered may result in the services (and supportive services) being denied which may apply financial liability to the member and/or provider depending upon contract arrangements.

Below are the standard product types that require a prior authorization for the Medical/Specialty Pharmacy (Rx) Drugs:

- BlueCare HMO

- My Blue*

- Medicare Advantage HMO*

- BlueOptions ACA Plans (Group & Individual plans)

- BlueChoice Group ACA Plans (effective 4/1/2016)

- Medicare Advantage PPO

- SimplyBlue Group

- Prior Authorization required in addition to referral when applicable

NOTE: Products that do not require authorization for the listed drugs are eligible for a Voluntary Predetermination of Select Services.

The Medical/Specialty Pharmacy (Rx) Drug List does NOT identify the following:

- Medical Specialty Pharmacy (Rx) Drugs listed do NOT guarantee coverage is available through the member's medical benefit. Eligibility and benefits (E&B) must be verified prior to providing services.

- The list does NOT identify prior authorization requirements for drugs processed and covered through the member's Pharmacy Benefit.

- The list should NOT be used as reference for BlueCard out-of-area members. Contact BlueCard Eligibility for out-of-area eligibility and coverage.

The HCPCS/CPT drug listing below is a catalog mapping HCPCS/J-codes to drug names, generic alternatives, internal flags (PADP, CEI, SAD) and relevant dates. Entries may indicate special handling such as “Drug not separately allowed, bundled within.” Presence on this list does NOT by itself indicate coverage; benefits vary by plan and prior authorization may still be required.

Representative entries (not exhaustive):

- C9399 — TYMLOS (ABALOPARATIDE) — SAD**L 08/02/2019

- C9399 — UKONIQ (UMBRALISIB) — SAD**L 05/01/2017

- C9399 — VANFLYTA (QUIZARTINIB) — SAD**L 02/05/2021

- C9399 — VARITHENA (POLIDOCANOL INJECTABLE FOAM) — SAD**L 07/28/2023 — COMMENTS: Drug not separately allowed, bundled within.

- J1559 — HIZENTRA (HUMAN IMMUNE GLOBULIN) — DRUG DATE 04/01/2010

- J1561 — GAMMAKED / GAMUNEX / GAMUNEX-C (HUMAN IMMUNE GLOBULIN) — various SAD flags and dates

- J1562 — VIVAGLOBIN — DRUG DATE 03/01/2006 — COMMENTS: product discontinued

- J1599 — YIMMUGO / Unclassified IVIG — DRUG DATE 06/13/2024

- J1930 — SOMATULINE DEPOT (LANREOTIDE) — PADP X — DRUG DATE 04/15/2010

- J2323 — TYSABRI (NATALIZUMAB) — PADP X — DRUG DATE 03/15/2008

- J2326 — SPINRAZA (NUSINERSEN) — DRUG DATE 12/28/2016

- J2506 — NEULASTA (PEGFILGRASTIM) — SAD flags — DRUG DATE 04/01/2002

- J2778 — LUCENTIS (RANIBIZUMAB) — DRUG DATE 10/15/2007

- J2820 — LEUKINE (SARGRAMOSTIM) — SAD flags — DRUG DATE 11/14/2016

- J2941 — GENOTROPIN / HUMATROPE / NORDITROPIN (SOMATROPIN) — SAD** flags

- J3490 / J3590 — Unclassified or miscellaneous drug codes (e.g., TOSYMRA, TRYNGOLZA, TYMLOS, VARITHENA, NEMLUVIO, NGENLA, NYPOZI) — various PADP/CEL/SAD flags and dates — some entries include: COMMENTS: Drug not separately allowed, bundled within.

Notes:

- Self-administered drugs may have limited benefits when billed through the medical benefit.

- New drugs approved by the FDA may not be listed immediately but could be subject to prior authorization.

- Drugs listed may not be covered by the member's benefits; verify eligibility and benefits before providing services.

- When new codes are assigned to drugs, search by HCPCS/CPT code and/or drug brand name to confirm processing and coverage.

The provided catalog does not include explicit coverage exclusions or determinations of “not medically necessary.” It functions as a mapping of codes to drug entries and internal flags. Any coverage determinations (including exclusions or medical necessity denials) are made based on the member's benefit plan, medical necessity criteria, and any applicable prior authorization or utilization management policies.

Additional provider guidance:

- Verify member eligibility and benefits prior to service.

- Confirm whether the member's plan requires prior authorization for the specific drug and administration route.

- Check if the drug is processed under the pharmacy benefit versus the medical benefit; prior authorization processes differ by benefit type.

Where entries indicate “Drug not separately allowed, bundled within,” the drug is considered part of another procedure or service for billing purposes and is not eligible for separate reimbursement. Providers should:

- Review the applicable procedure or bundle billing guidance before submitting claims.

- Confirm with the payer if separate reimbursement is appropriate in exceptional circumstances and obtain prior authorization when required.

This section contains only code-to-drug mappings and administrative flags. It does not itself establish clinical coverage rules or exclusions. Coverage is determined by the applicable benefit contract and utilization management policies.

Drugs included in the HCPCS/J-code catalog may be subject to plan-specific coverage limitations. Prior to providing services or submitting claims, verify:

- Member eligibility and plan benefits via Eligibility & Benefits (E&B) systems.

- Whether the drug is covered under the medical benefit or the pharmacy benefit.

- Any prior authorization, step therapy, quantity limits, or other utilization management requirements.

This segment is informational and lists HCPCS/CPT codes with associated drug names and administrative flags. It does not provide clinical criteria or medical necessity rules. For clinical coverage criteria, refer to the payer's utilization management and medical necessity policy documents.

The provided content does not include determinations of procedures or drugs being 'not medically necessary.' Coverage decisions of that nature are handled through separate clinical policy documents and prior authorization determinations.

This document section is a catalog-style listing used for reference mapping of HCPCS/CPT codes to drug brand names, generic equivalents, and internal administrative flags (PADP, CEI, SAD) along with effective or listed dates. It is maintained to support coding, billing, and prior authorization workflows. Updates to codes and new drug approvals may be reflected periodically; always confirm current coding and coverage status before billing.