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).

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.

• Unclassified/NOC codes on the PADP Unclassified HCPCS Drug List (e.g., J9999, J3590, J1599) require prior authorization effective on the PADP effective dates shown.
• The PADP Unclassified HCPCS Drug List includes the drug name, generic/description, and PADP effective date for each entry.

Documentation Expectations for Prior Authorization

Document clinical rationale and supporting medical records when submitting prior authorization requests. Include diagnosis, prior treatments, relevant labs/imaging, and planned administration details (dose, frequency, place of service).

• Documentation supporting medical necessity must be available for review and may be required to complete the PADP prior authorization.
• When member product requires a specialist referral or home nursing prior authorization, these are reviewed separately by Florida Blue per normal processes.

Unclassified HCPCS / HCPCS Assignment & Billing Guidance

Billing and coding guidance for NOC/unclassified and newly assigned HCPCS: continue to bill using the applicable unclassified/NOC HCPCS (J9999, J1599, J3590, A9699, etc.) for products not yet assigned a permanent HCPCS. Once CMS assigns a permanent HCPCS to a drug previously billed to an unspecified/NOC code, the new HCPCS will be included in the PADP Drug List and managed by Magellan Rx Management.

• Do not bill drugs associated to J9999 with C9399; MRxM authorizations will not be applied when billing C9399.
• C-codes are billable only in the Hospital Outpatient setting for specified drugs; other settings must use the unspecified drug HCPCS until a permanent HCPCS is assigned by CMS.
• When a new permanent HCPCS is assigned, the permanent code will be added to the PADP Drug List and prior authorization requirements will follow that listing.

Benefit-Arrangement Based Requirements

Prior authorization requirements depend on the member benefit arrangement and provider contract. Some member products require prior authorization for PADP drugs (see PADP member benefit lists); others may be eligible for a Voluntary Predetermination of Select Services (VPSS). Verify the member's product and applicable provider arrangement before administering drugs.

• Member benefit arrangements that require prior authorization include BlueCare HMO, SimplyBlue, My Blue (prior auth in addition to referral when applicable), BlueSelect, BlueOptions ACA/CE, and BlueChoice where applicable.
• If a provider contract or member arrangement does not require prior authorization, providers may request a VPSS for PADP drugs; VPSS reviews for PADP drugs are performed by Prime Therapeutics Management MPS division.
• A separate authorization for administration/per diem services is not required when the member product requires prior authorization for the drug unless specifically identified.

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.

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.