Prior Authorization Required

Florida Blue has contracted with Prime Therapeutics Management MPS division (formerly Magellan Rx Management / MRxM ICORE) to manage the Provider-Administered Drug Program (PADP). Providers must obtain prior authorization from MRxM for PADP-listed drugs when the member product/benefit requires prior authorization. If prior authorization is not obtained for an applicable PADP drug, payment may be denied and the Member cannot be held responsible for denied charges.

• Member products requiring prior authorization include: BlueCare HMO (Group & Individual), SimplyBlue, My Blue, BlueSelect, BlueOptions ACA CE Plans (Group & Individual), BlueChoice Group ACA/CE Plans, and other member arrangements listed in the PADP/Medical and Specialty Drug UM lists.
• Providers participating with Florida Blue Utilization Management Programs (PADP) must obtain prior authorization for PADP drugs prior to administration.
• Voluntary Predetermination of Select Services (VPSS) is available for member/provider arrangements that do not require prior authorization; VPSS for PADP drugs is reviewed by MRxM.
• When a member product requires a referral or separate prior authorization for home nursing or specialist referral, those will be reviewed separately by Florida Blue.

Use Listed HCPCS/J-code

Use the HCPCS / J-code listed in the PADP Drug List when submitting claims or prior authorization requests. When a drug has been assigned a specific HCPCS (including J-codes), that HCPCS must be used for billing and for MRxM management.

• Use the listed HCPCS/J-code on claims and prior authorization submissions for PADP drugs.
• If a drug has been assigned a new HCPCS, the HCPCS will be included in the PADP Drug List and managed by MRxM going forward.
• C-codes are only billable for the specified drug services within the Hospital Outpatient setting; other settings must use the corresponding unspecified drug HCPCS until a listed HCPCS is assigned by CMS.

Codes Managed by MRxM PADP (partial list)

Inclusion of a HCPCS/J-code in the PADP Drug List indicates the product is managed by MRxM and prior authorization applies per member benefit requirements. The PADP listing includes an effective date and, where applicable, a termination date for each code — providers should reference those PADP effective/termination dates when determining management and authorization applicability.

• Inclusion in the PADP list implies MRxM management and that prior authorization requirements apply.
• Each PADP entry includes PADP EFF DATE and TERMDATE (if applicable) — verify these dates when checking whether a code is managed.
• The PADP list contains a partial set of HCPCS/J-codes (examples include J1568, J1599*, J1602, J1627, J1628, J2506, J2507, J9047, J9048, J9061, J9118, J9144, Q2049, Q5101, Q5103, etc.).

Authorization Interaction with Unspecified Drug Code C9399

Some PADP entries use unspecified/unclassified HCPCS (for example J1599*, J9999*, J3590*). When drugs are billed using an unspecified code such as C9399 or certain J-/unclassified codes, MRxM authorizations may not be applied. Specifically, drugs associated to J9999 are noted as NQI accepted with C9399 and MRxM authorizations will not be applied when billing C9399.

• When a drug is assigned to a specific HCPCS, it will be managed through MRxM; however, billing with unspecified codes (e.g., C9399) can prevent MRxM authorization from applying.
• Drugs associated with J9999 are NQI accepted with C9399; MRxM authorizations will not be applied when billing C9399.
• Providers must avoid using C9399 when a specific PADP HCPCS exists and should bill the assigned HCPCS to ensure MRxM prior authorization is applied.

Step / Addition Management — Periodic Updates

Step therapy, additions, and periodic updates: the PADP drug list is updated periodically. Additions to the PADP Drug List will be made periodically and may change which products require MRxM prior authorization. Providers should monitor PADP updates for new HCPCS assignments and step/addition management changes.

• PADP additions and updates are performed periodically — newly assigned HCPCS will be added to the PADP list and managed by MRxM on their PADP EFF DATE.
• Step therapy rules and specific step/addition details are maintained in PADP update notices or companion step therapy documents; check the PADP and Medical/Specialty Drug UM lists for current requirements.
• Failure to follow updated step therapy or prior authorization processes may result in claim denials.

PADP applies to listed places of service

PADP management and prior authorization requirements apply when administration occurs in the listed places of service, including outpatient (on- and off-campus), office, ambulatory infusion suite (AIS), other outpatient centers, home, and clinics.

• Verify place of service to determine PADP applicability and prior authorization routing.

C-code billing limited to Hospital Outpatient setting

C-codes are only billable for the specified drug services within the Hospital Outpatient setting; all other settings must be billed with the corresponding unspecified drug HCPCS until CMS assigns a listed HCPCS.

• Do not use C-codes outside Hospital Outpatient for PADP drugs; use unspecified HCPCS (e.g., J9999/J3590) instead.

Step therapy not provided in this segment

No step therapy information is specified in this PADP segment; providers should consult separate step therapy or Medical and Specialty Drug UM List resources if step requirements are needed.