CurrentFlorida BluePolicy N/A

Provider‑Administered Drug Program (PADP) — MRxM (Prime Therapeutics) management and prior authorization

Defines Florida Blue's PADP utilization management handled by Prime Therapeutics (MRxM) for a listed set of provider‑administered medications and the requirement that participating providers obtain prior authorization before drug administration. Applies to covered Florida Blue member products and specified places of service.

Policy Summary

PayerFlorida Blue

PolicyProvider‑Administered Drug Program (PADP) — MRxM management and prior authorization

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from Prime Therapeutics (MRxM) for PADP‑listed drugs prior to administration when required by the member's benefit plan or provider contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200+Listed codes/drugs

Since July 2009Managed since

Prior authorization requiredAuth required

Most include eff datesEntries with dates

MultiplePlaces of service

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Coverage Criteria

General PADP prior authorization criteria

Covered when ALL of the following are met:

PADP prior auth required: Provider must obtain prior authorization from Prime Therapeutics Management (MRxM) for drugs included on the PADP Drug List prior to administration when the member's benefit plan or provider contract requires prior authorization.

If prior authorization is not obtained, payment for the service may be denied and the member cannot be held responsible for denied charges.

Applicable member products and places of service: The PADP prior authorization requirement applies for covered member products and places of service managed by MRxM (examples include BlueCare HMO, SimplyBlue, My Blue, BlueOptions, BlueSelect, BlueChoice, Medicare Part B Primary as specified, office, ambulatory infusion suite (AIS), other outpatient centers, home, and clinics).

Medicare Advantage HMO & PPO effective 07/01/2021 are excluded from MRxM management per the PADP document.

Code and documentation requirement: Providers must reference the exact HCPCS/J-code and corresponding drug name from the MRxM PADP list when requesting prior authorization or submitting claims to ensure correct management and benefits adjudication.

Each PADP HCPCS entry includes an effective date and termination date; providers should verify the PADP effective/termination dates for the date of service.

Unclassified/unspecified HCPCS and billing note: Drugs billed using unclassified or unspecified HCPCS (for example J9999, J3590, J1599, A9699) included on the PADP Drug List are managed by MRxM and require prior authorization when applicable.

Billing with C9399 (unspecified drug C-code) will not trigger MRxM authorizations; MRxM authorizations will not be applied when billing C9399. C-codes are only billable for specified drug services in the Hospital Outpatient setting.

Providers that participate with Florida Blue Utilization Management Programs (PADP) must obtain prior authorization from Prime Therapeutics (MRxM) for drugs included on the PADP Drug List prior to administration when the member's benefit product or provider contract requires it. PADP has been managed by Prime Therapeutics (MRxM) since July 2009 and applies to the member products and places of service listed in the program; if prior authorization is not obtained, payment for that service will be denied and the member cannot be held responsible for the denied charges.

Use the specific HCPCS/C code guidance in the PADP list when billing. C-codes are only billable for the specified drug services within the Hospital Outpatient setting; for all other places of service providers must bill using the corresponding unspecified or unclassified HCPCS (for example, J9999, J3590, J1599 or other unspecified HCPCS) until CMS assigns a permanent HCPCS. Note that drugs associated to J9999 are NQI accepted with C9399 and MRxM authorizations will not be applied when billing C9399.

HCPCS / J-code List and Coding Notes

PADP Listed HCPCS / J-codes (selected)HCPCSCovered

J9024	ATEZOLIZUMAB & HYALURONIDASE (TECENTRIQ HYBREZA)
J9025	AZACITIDINE (VIDAZA)
J9026	TARLATAMAB-DLLE (IMDELLTRA)
J9028	NOGAPENDEKIN ALFA INBAKICEPT-PMLN (ANKTIVA)
J9029	NADOFARAGENE FIRADENOVEC-VNCG (ADSTILADRIN)
J9032	BELINOSTAT (BELEODAQ)
J9033	BENDAMUSTINE (TREANDA)
J9034	BENDAKA / BENDEKA (BENDAMUSTINE)
J9035	BEVACIZUMAB (AVASTIN - oncology use)
J9036	BENDAMUSTINE HCL (BELRAPZO)

1–10 of 19

1/2

Covered HCPCS / J-codes (partial)HCPCSCovered

J9171	DOCETAXEL (DOCEFREZ / TAXOTERE)
J9172	DOCETAXEL
J9173	DURVALUMAB (IMFINZI)
J9176	ELQTUZUMAB (EMPLICITI)
J9177	ENFORTUMAB VEDOTIN (PADCEV)

Covered HCPCS / J-codes (partial)HCPCSCovered

J9198	GEMCITABINE HYDROCHLORIDE (INFUGEM)
J9202	GOSERELIN ACETATE (ZOLADEX)
J9203	GEMTUZUMAB-OZOGAMICIN (MYLOTARG)

Covered HCPCS / J-codes (partial)HCPCSCovered

J9227	ISATUXIMAB-IRFC (SARCLISA)
J9228	IPILIMUMAB (YERVOY)
J9229	BESPONSA

Covered HCPCS / J-codes (partial)HCPCSCovered

J9301	OBINUTUZUMAB (GAZYVA)
J9302	QFATUMUMAB (ARZERRA)
J9303	PANITUMUMAB (VECTIBIX)
J9304	PEMETREXED (PEMFEXY)

Covered HCPCS / J-codes (continued, partial)HCPCSCovered

J9316	PERTUZUMAB_TRASTUZUMAB_and HYALURONIDASE (PHESGO)
J9321	EPCORITAMAB-BYSP (EPKINLY)
J9325	TALIMOGENE LAHERPAREPVEC (IMLYGIC)
J9330	TEMSIROLIMUS (TORISEL)
J9332	EFGARTIGIMOD ALFA-FCAB (VYVGART)
J9333	ROZANOLIXIZUMAB-NOLL (RYSTIGGO)
J9347	TREMELIMUMAB-ACTL (IMJUDO)
J9348	NAXITAMAB-GQGK (DANYELZA)

Listed J-codes (partial)HCPCSCovered

J9048

BORTEZOMIB (alternate HCPCS effective 01/01/2023)

Listed J-codes (continued)HCPCSCovered

J9049	BORTEZOMIB (alternate HCPCS effective 01/01/2023)
J9055	CETUXIMAB (ERBITUX)
J9056	BENDAMUSTINE HYDROCHLORIDE (VIVIMUSTA)
J9061	AMVANTAMAB-VMJW (RYBREVANT)

More J-codesHCPCSCovered

J9144	DARATUMUMAB & HYALURONIDASE (DARZALEX FASPRO)
J9145	DARATUMUMAB (DARZALEX)
J9161	DENILEUKIN DIFTITOX-CXDL (LYMPHIR)
J9179	ERIBULIN (HALAVEN)
J9198	GEMCITABINE (INFUGEM)

Additional J-codesHCPCSCovered

J9161	DENILEUKIN DIFTITOX-CXDL (LYMPHIR)
J1307	CROVALIMAB-AKKZ (PIASKY)
J08Z0	New HCPCS example (placeholder for specified agent)

Q-codes and new HCPCS entriesHCPCSCovered

Q5146	TRASTUZUMAB-STRE (HERCESSI)
Q5147	AFLIBERCEPT-AYYH (PAVBLU)
Q5148	FILGRASTIMTXID (NYPOZI)
Q5149	AFLIBERCEPT-ABZV (ENZEEVU)
Q5150	AFLIBERCEPT-MRBB (AHZANTIVE)
Q5151	ECULIZUMAB-AAGH (EPYSQLI)
Q5152	ECULIZUMAB-AEEB (BKEMV)

Listed specific Q/Q999 HCPCS codes in PADP listHCPCSCovered

Q5146	HERCESSI (TRASTUZUMAB-STRE)
Q5147	PAVBLU (AFLIBERCEPT-AYYH)
Q5148	NYPOZI (FILGRASTIMTXID)
Q5149	ENZEEVU (AFLIBERCEPT-ABZV)
Q5150	AHZANTIVE (AFLIBERCEPT-MRBB)
Q5151	EPYSQLI (ECULIZUMAB-AAGH)
Q5152	BKEMV (ECULIZUMAB-AEEB)

Unclassified / Unlisted HCPCS and general billing notesHCPCS

J9999	Unclassified antineoplastic / NOC — used when CMS has not assigned a specific HCPCS; PADP manages drugs under J9999/J3590/J1599 etc.
J3590	Unclassified biologics — used for products pending specific HCPCS assignment
C9399	Not otherwise classified drug — NQI accepted for drugs associated to J9999; authorizations not applied when billing C9399

Provider Actions and Prior Authorization Procedure

Prior Authorization

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.

Places of Service and Billing Implications

Documentation Required

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.

Billing Rule

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 Notes

Step Therapy

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.