CurrentFlorida BluePolicy N/A

Provider Administered Drug Program (PADP) — Prior Authorization and PADP Drug List

Defines the Provider Administered Drug Program (PADP) managed by Prime Therapeutics (Magellan Rx Management) for Florida Blue and Health Options, specifying which provider settings, member products, and HCPCS/J-codes require prior authorization and are managed under the program.

Policy Summary

PayerFlorida Blue

PolicyProvider Administered Drug Program (PADP) — Prior Authorization and PADP Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective Dateas written

Next Review DateN/A

Key ActionObtain prior authorization from Prime Therapeutics (Magellan Rx Management) for listed PADP HCPCS/J/Q codes before administering or billing the drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200+listed HCPCS/J-codes/drugs in this partial extract

~120+distinct HCPCS/J codes listed in this excerpt

AllApplies to member benefit arrangements

includes J9999Unclassified/NOC HCPCS referenced

Medicare Part BExcluded from PADP management

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Coverage Criteria

The following member products, provider types and benefit arrangements are excluded from MRxM (PADP) management: Medicare Part B Primary, FEP (Federal Employee Program), BlueCard Host, Be Healthy, Medicare Advantage HMO & PPO, Medicare Supplement, and CareCentrix providers when services are In‑State Home or Ambulatory Infusion Suite (AIS) (CareCentrix will perform prior authorization for those CareCentrix cases). In addition, drugs that are covered and processed through the Pharmacy Benefit (PBM or Part D) are not managed by MRxM. Providers participating in Florida Blue PADP should confirm whether the member’s benefit arrangement places the drug under PADP or routes prior authorization elsewhere prior to administration.

When billing with unclassified/unspecified HCPCS, note that drugs associated to J9999 are NOT accepted with C9399. Per the PADP guidance, Magellan Rx Management (MRxM) authorizations will not be applied when claims are billed with C9399. Ensure the correct HCPCS is used—once CMS assigns a permanent HCPCS to a product it will be added to the PADP Drug List and managed through MRxM.

HCPCS / J-code Lists

PADP Managed HCPCS/J-codes list (partial)HCPCSCovered

A9513	LUTETIUM LU 177
A9543	IBRITUMOMAB TIUXETAN
A9590	IODINE I-131 IOBENGUANE
A9600	STRONTIUM SR-89 CHLORIDE
A9604	SAMARIUM SM-153 LEXIDRONAM
A9606	RADIUM RA223 DICHLORIDE THER
A9607	LUTETIUM (177LU) VIPIVOTIDE TETRAXETAN
A9699	UNCLASSIFIED RADIOPHARMACEUTICAL
J0013	ESKETAMINE (SPRAVATO)
J0129	ABATACEPT (ORENCIA IV)

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Continuation of listed HCPCS/J codesHCPCSCovered

J1439	INJECTAFER / FERRIC CARBOXYMALTOSE
J1440	REBYOTA / FECAL MICROBIOTA, LIVE-JSLM
J1442	NEUPOGEN / FILGRASTIM
J1447	GRANIX / TBO-FILGRASTIM
J1448	COSELA / TRILACICLIB
J1449	ROLVEDON / EFLAPEGRASTIM-XNST
J1453	EMEND / FOSAPREPITANT
J1454	AKYNZEO / FOSNETUPITANT & PALONOSE
J1458	NAGLAZYME / GALSULFASE
J1459	PRIVIGEN / HUMAN IMMUNE GLOBULIN

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HCPCS J-code list requiring prior authorizationHCPCSCovered

J7324	HIGH MOLECULAR WEIGHT HYALURONAN INJECTION
J7325	HYLAN G-F 20 (SYNVISC / SYNVISC ONE)
J7326	CROSS-LINKED HYALURONATE (GEL-ONE)
J7327	HIGH MOLECULAR WEIGHT HYALURONAN (MONOVISC)
J7328	HYALURONAN/DERIVATIVE (GEL-SYN)
J7329	HYALURONAN/DERIVATIVE (TRIVISC)
J7331	SYNOJOYNE (SYNOJOYT)
J7332	TRILURON
J7352	AFAMELANOTIDE (SCENESSE)
J7354	CANTHARIDIN (YCANTH)

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PADP HCPCS/J/Q Codes (excerpt)HCPCSCovered

J9314
J9316	PHESGO; PERTUZUMAB, TRASTUZUMAB, and HYALURONIDASE-ZZXF
J9317	TRODELVY; SACITUZUMAB GOVITECAN-HZIY
J9318	ROMIDEPSIN, non-lyophilied
J9319	ISTODAX; ROMIDEPSIN, lyophilied
J9321	EPKINLY; EPCORITAMAB-BYSP
J9322	PEMETREXED
J9323	PEMETREXED
J9324	PEMYRDI RTU / PEMETREXED
J9325	IMLYGIC; TALIMOGENE LAHERPAREPVEC

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Temporary and newly assigned HCPCS/C/Q codes mentionedmixed

J3590	Unclassified drug/biological
J9999	Not otherwise classified drugs (J9999 used as unspecified)
J1599	Unclassified drugs — immune globulin IV referenced
J3402	New HCPCS effective 10/01/2025 referenced for remestemcel-L-RKND
J9184	Gemcitabine — new HCPCS reference (effective 01/01/2026) for AVGEMSI
J9256	Nipocalimab — new HCPCS reference (effective 01/01/2026) for IMAAVY
J9282	Mitomycin — new HCPCS reference (effective 01/01/2026) for ZUSDURI
J9011	Datopotamab deruxtecan — new HCPCS reference (effective 10/01/2025) for DATROWAY
Q5160	New Q-code referenced for bevacizumab biosimilar (effective 01/01/2026)
Q5154	New Q-code referenced for omalizumab (effective 10/01/2025)

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Provider Actions & Billing Rules

Prior Authorization

Prior Authorization Required

Providers must obtain prior authorization for physician-administered drugs listed on the PADP Drug List (including drugs billed to unclassified/NOC HCPCS) before administration. Claims for listed HCPCS/J/Q codes submitted without required prior authorization may be denied and payment withheld; the member cannot be held responsible for charges denied due to missing authorization.

Prior authorization is required for all PADP-listed HCPCS/J/Q codes and associated drug products prior to service.
If a prior authorization is not obtained as required by the member benefit arrangement, payment for the service may be denied.
Providers participating in Florida Blue Utilization Management Programs (PADP) must request prior authorization through Magellan Rx Management (Prime Therapeutics Management MPS division).

Prior Authorization

PADP Unclassified HCPCS Drugs — Prior Authorization Required

PADP includes a list of specifically coded HCPCS/J/Q drugs and a list of drugs currently billed to unclassified or NOC codes (for example J9999, J1599, J3590, A9699, Q9999). Prior authorization is required for both specifically listed HCPCS codes and those on the PADP Unclassified HCPCS Drug List.

Background

The Provider Administered Drug Program (PADP) utilization management program is intended to ensure proposed provider‑administered medications meet medical necessity under the member’s benefit plan and to manage utilization for select physician/healthcare professional administered medications. PADP has been managed by Prime Therapeutics Management (formerly Magellan Rx Management) since July 2009. Participating Florida Blue providers are required to obtain prior authorization for PADP‑listed drugs before administration; claims for PADP drugs submitted without required prior authorization may be denied and the member cannot be held responsible for denied charges.

Definitions

PADP / MRxM Management

Program nameProvider Administered Drug Program (PADP) managed by Prime Therapeutics Management MPS division (formerly Magellan Rx Management / MRxM)

Scope of managementPrior authorizations, voluntary pre-determinations (VPSS), and advanced organizational determinations (SAO) for designated provider-administered medications

Effective sincePADP managed by Prime Therapeutics Management MPS division since July 2009

Place of service includedOutpatient (on- & off-campus), ambulatory surgery centers, home, clinics, offices, ambulatory infusion suites, and other outpatient centers

Who performs reviewsPrime Therapeutics Management MPS division (formerly known as Magellan Rx Management) performs PADP prior authorization reviews

Site of Care Applicability

Prior Authorization

Obtain PA for PADP drugs in outpatient settings

PADP prior authorization and management apply when drugs are administered in outpatient settings (on‑ and off‑campus), ambulatory surgery centers, home, clinics, offices, ambulatory infusion suites (AIS), and other outpatient centers; ensure PA is obtained for services in these settings.

Billing Rule

Use C‑codes only in Hospital Outpatient when allowed

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