CurrentMass General Brigham Health PlanPolicy N/A

Medical Specialty Medications - Specialty Fusion Prior Authorization List (partial)

Section of the Mass General Brigham Health Plan Specialty Fusion prior authorization list (Commercial/Exchange) showing HCPCS/CPT codes, product mappings and flags for Dual Benefit and Site of Care for specialty medications.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Specialty Medications - Specialty Fusion Prior Authorization List (partial)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Dateas written

Next Review Date

Key ActionProviders and billing staff must reference the listed HCPCS/CPT codes and the 'X' flags for Dual Benefit and Site of Care when submitting prior authorization requests and billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplemedications / HCPCS entries listed (partial document)

Commercial/Exchangeplan applicability

08/01/2025list last updated (header)

~300code-to-product mappings shown in this part

someentries marked with 'X' (flag present)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Policy snapshot

This document is a section of the Mass General Brigham Health Plan Specialty Fusion Prior Authorization List for medical specialty medications (Commercial/Exchange). It shows HCPCS/CPT codes mapped to drug names and short HCPCS descriptors and includes program flags used by the plan for administration of specialty medications. The extract is a partial listing of the larger master list and is intended to help billing and clinical operations staff identify the correct billing codes and any plan flags that affect prior authorization and site-of-care considerations.

Subject: Medical Specialty Medications - Specialty Fusion Prior Authorization List (partial). Status: CURRENT. List header shows: Updated 08/01/2025 and the effective dating is shown as as written in this partial document.

Summary facts (partial list)

medications / HCPCS entries listed (partial document)multiple (hundreds)

plan applicabilityCommercial/Exchange

list last updated (header)Updated 08/01/2025

code-to-product mappings shown in this part~300

entries include J-, Q-, C-, S- and unclassified (J3490*) codesmultiple

entries marked with "X" (flag present) indicating special note/statussome

Document context and intended use

Background: This file is a section of the Specialty Fusion prior authorization list and is provided for billing and clinical operations staff who prepare prior authorization requests and submit claims. It lists HCPCS/CPT codes, associated specialty medication product names, short HCPCS descriptors, and flags (marked as 'X') that indicate items designated for Dual Benefit or with a Site of Care note; operational criteria and submission instructions are contained in the full prior authorization policy or provider portal referenced by the plan.

HCPCS / CPT code listings and mappings

Listed specialty medication HCPCS/CPT codes (partial extract)HCPCS|CPT

J3262	Actemra; Injection, tocilizumab, 1 mg; Dual Benefit: X; Site of Care: X
J2504	Adagen; Injection, pegademase bovine, 25 IU
J0791	Adakveo; Injection, crizanlizumab-tmca, 1 mg; Site of Care: X
J7192	Advate / Kogenate FS / Recombinate; Factor VIII (antihemophilic factor, recombinant) per IU; Dual Benefit: X
J7207	Adynovate; injection, factor VIII (recombinant) pegylated, 1 IU; Dual Benefit: X
J7171	Adzynma; Injection, adamts13, recombinant-krhn, 10 IU
J7210	Afstyla; Injection, Factor VIII (recombinant) (Afstyla), 1 IU; Dual Benefit: X
J1931	Aldurazyme; Injection, laronidase, 0.1 mg; Dual Benefit: X
J9305	Alimta (pemetrexed), 10 mg
J7186	Alphanate / VWF Complex (human); Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII IU; Dual Benefit: X

1–10 of 60

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HCPCS/J/Q/C/S code mappings to medication product and billing description (extracted entries)mixed

J1602	Injection, pasireotide long acting, 1 mg = Injection, golimumab, 1 mg, for intravenous use
J2327	Injection, pasireotide long acting, 1 mg = Injection, risankizumab-rzaa, intravenous, 1 mg
J7331	Injection, pasireotide long acting, 1 mg = Hyaluronan or derivative, Synojoynt, for intra-articular injection, 1 mg
J1299	Injection, pasireotide long acting, 1 mg = Injection, eculizumab, 10 mg
J1930	Injection, pasireotide long acting, 1 mg = Injection, lanreotide, 1 mg
J3490*	Unclassified drug code mapping examples: pasireotide long acting mapping to pegvisomant subcutaneous use; terlipressin, selexipag IV and others referenced under J3490*
J1747	Injection, pasireotide long acting, 1 mg = Injection, spesolimab-sbzo, 1 mg
J2326	Injection, pasireotide long acting, 1 mg = Injection, nusinersen, 0.1 mg
S0013	Injection, pasireotide long acting, 1 mg = Esketamine, nasal spray, 1 mg (Spravato) -- note: provider payment guidelines reference for G2082/G2083
J3358	Injection, pasireotide long acting, 1 mg = Ustekinumab, for intravenous injection, 1 mg

1–10 of 77

1/8

Some mappings in this list include manufacturer-specific non-equivalent codes and unclassified (J3490*) mappings. Examples shown in the extract include non-equivalent pemetrexed entries (e.g., J9292 / J9305 entries), biosimilar or manufacturer-specific bortezomib variations (J9041 vs J9046/J9048/J9049/J9051), and numerous product mappings reported under J3490*. The listing also cross-references certain nasal or payment-guideline-sensitive codes (for example, the G2082/G2083 / S0013 Spravato reference) where Provider Payment Guidelines should be consulted.

Billing and prior-authorization guidance

Documentation Required

Prior Authorization and Site-of-Care flags

This list provides HCPCS/CPT codes with flags for 'Dual Benefit' and 'Site of Care' (marked as 'X' in the table). Providers and billing staff must reference these flags when submitting prior authorization requests and when determining site-of-care requirements; specific PA criteria and submission instructions are not present in this partial document and must be obtained from the full prior authorization policy or portal.

Flags shown as "X" in code listing — reference full PA policy/portal for operational rules.

Billing Rule

Use exact HCPCS/CPT code listed

Billing must use the HCPCS/CPT codes as listed (including manufacturer- or product-specific codes where present). Several medications have multiple non-therapeutically-equivalent HCPCS codes (manufacturer-specific) — use the correct code for the product administered.

Terms and flags used in the listing

Definitions (as shown in list)

Dual BenefitColumn in the list indicating whether the item is designated 'Dual Benefit' for plan administration; marked with 'X' where applicable. (Document does not define further.)

Site of CareColumn indicating a site-of-care requirement/flag; marked with 'X' where applicable. (Full operational details are in the broader policy or prior authorization system.)

Specialty Fusion Prior Authorization ListA master list of HCPCS/CPT codes mapped to specialty medication product names and flags used to manage prior authorization and site-of-care for specialty medications under the payer's Commercial/Exchange lines.

X flagEntries marked with 'X' appear in the source as a flag; the document does not define its meaning in this part — likely indicates special status or billing note.

J3490*Unclassified drug/biological code used when no specific HCPCS code exists; multiple product mappings appear under this code in the listing.

Document changes

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No material changes listed in this partial document (brief.has_material_change=false).