CurrentMass General Brigham Health PlanPolicy N/A

Medical benefit coverage and prior authorization status for injectable/oral drugs (J/C/Q codes)

Lists which specific drugs (by HCPCS/Q codes) are not covered under the medical benefit and should be redirected to pharmacy, which are new-to-market and require prior authorization, and which require or do not require prior authorization across Commercial, MGB ACO, and Medicare Advantage products. Affects providers submitting medical benefit claims and utilization management staff for Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical benefit coverage and prior authorization status for injectable/oral drugs (J/C/Q codes)

Policy CodePolicy N/A

Change TypeTechnical update — no material coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionRedirect drugs listed as 'Not covered' to the pharmacy and obtain prior authorization where required for Commercial, MGB ACO, and Medicare Advantage product lines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3product lines covered

>=30unique HCPCS/Q codes cited

multipledistinct drug lists

sectionspolicy sections

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.

Not covered / Redirect to pharmacy

Codes listed here are not covered under the medical benefit and should be redirected to the pharmacy for the specified product line.

Not covered under the medical benefit; redirect to pharmacy for MGB ACO: J0601, J0602, J0603, J0605, J0607, J0608, J0609, J0615, J7514, J7601, Q0155, Q5140, Q5141, Q5142, Q5143, Q5144

Not covered under the medical benefit; redirect to pharmacy for Commercial: J0139, J0601, J0602, J0603, J0605, J0607, J0608, J0609, J0615, J0901, J7514, J7601, Q0155, Q5140, Q5141, Q5142

New to Market — prior authorization

New-to-market items require prior authorization for the listed product lines.

New to Market — Commercial: C9173, J9292, Q5139, Q5146, Q9996, Q9997, Q9998, J0901 (as listed)

New to Market — MGB ACO: C9173, J0901, Q5139, Q9997

New to Market — Medicare Advantage: Q5139, Q5146, Q9996, Q9997, Q9998

Prior authorization required

Specified drugs require prior authorization for the listed product lines.

Prior authorization required — Commercial: J0870, J1307, J1414, J1552, J2802, J3392, J9026, J9028

Prior authorization required — MGB ACO: J0870, J1307, J1414, J1552, J2802, J3392, J9026, J9028, J9292, Q5146

Prior authorization required — Medicare Advantage: C9173, J0870, J1307, J1414, J3392, J9026, J9028, J9292

No prior authorization required

These codes do not require prior authorization for the specified product lines.

No prior authorization required — Commercial: J0666, J2290, J2472, J9076

No prior authorization required — MGB ACO: J0139, J0666, J2290, J2472, J9076

No prior authorization required — Medicare Advantage: J0601, J0602, J0603, J0605, J0607, J0608, J0609, J0615, J0666, J0901, J1552, J2290, J2802, J7514, J7601, J9076, Q0155

Billing Codes and Coding Guidance

Oral phosphate/iron/ESRD-related agentsHCPCS

J0601	Sevelamer carbonate (Renvela or equivalent), oral, 20 mg (for ESRD on dialysis)
J0602	Sevelamer carbonate, oral powder, 20 mg (for ESRD on dialysis)
J0603	Sevelamer hydrochloride (Renagel or equivalent), oral, 20 mg (for ESRD on dialysis)
J0605	Sucroferric oxyhydroxide, oral, 5 mg (for ESRD on dialysis)
J0607	Lanthanum carbonate, oral, 5 mg (for ESRD on dialysis)
J0608	Lanthanum carbonate, oral powder, 5 mg (not therapeutically equivalent to J0607)
J0609	Ferric citrate, oral, 3 mg ferric iron (for ESRD on dialysis)
J0615	Calcium acetate, oral, 23 mg (for ESRD on dialysis)

Maximum dosing guidance

Q0155 maximum regimenDronabinol (Syndros) Q0155: oral 0.1 mg as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy; not to exceed a 48-hour dosage regimen.

Other dosing notes presentNo additional maximum dosing limits are documented in the source for listed HCPCS/Q codes in this policy beyond the Q0155 48-hour limit.

ContextMaximum dosing guidance is recorded where present in coding thresholds (example shown for Q0155).

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed drugs when billed under the medical benefit for the specified product lines. Submit prior authorization requests per payer requirements to avoid claim denials.

Commercial: J0870, J1307, J1414, J1552, J2802, J3392, J9026, J9028
MGB ACO: J0870, J1307, J1414, J1552, J2802, J3392, J9026, J9028, J9292, Q5146
Medicare Advantage: C9173, J0870, J1307, J1414, J3392, J9026, J9028, J9292

Billing Rule

Redirect to Pharmacy / Not Covered Under Medical Benefit

The following HCPCS/CPT codes are not covered under the medical benefit and should be redirected to the pharmacy channel for dispensing. Billing these codes on the medical benefit may result in denial; providers must submit these through pharmacy where applicable.

MGB ACO: J0601, J0602, J0603, J0605, J0607, J0608, J0609, J0615, J7514, J7601, Q0155, Q5140, Q5141, Q5142, Q5143, Q5144, Q5145, Q5146, Q9996, Q9998
Commercial: J0139, J0601, J0602, J0603, J0605, J0607, J0608, J0609, J0615, J0901, J7514, J7601, Q0155, Q5140, Q5141, Q5142
Note: Codes listed under 'Not covered under medical benefit; Redirect to pharmacy' must be routed to pharmacy benefit when applicable.

Note

No Prior Authorization Required

The following codes do not require prior authorization when billed to the specified product lines.

Commercial (no PA): J0666, J2290, J2472, J9076
MGB ACO (no PA): J0139, J0666, J2290, J2472, J9076
Medicare Advantage (no PA): J0601, J0602, J0603, J0605, J0607, J0608, J0609, J0615, J0666, J0901, J1552, J2290, J2802, J7514, J7601, J9076, Q0155

Definitions and Terminology

Not covered under medical benefit — redirect to pharmacy

DefinitionNot covered under the medical benefit: Codes listed as ‘Not covered’ should be redirected to the pharmacy rather than billed to the medical benefit.

Applies to product linesSpecified redirect-to-pharmacy directives are applied for MGB ACO and Commercial product lines as listed in the policy.

Example codesExamples of codes redirected to pharmacy include J0601, J0602, J0603, J0605, J0607, J0608, J0609, J0615, J7514, J7601, Q0155, Q5140–Q5145, and J0139.

New to Market — prior authorization / coverage

DefinitionNew to Market: Items newly marketed that are not covered under the medical benefit unless prior authorized for the specified product lines.

Applies to product linesNew-to-market prior authorization requirements are specified per product line (Commercial, MGB ACO, Medicare Advantage) in the policy.

Example new-to-market codesC9173, J9292, Q5139, Q5146, Q9996, Q9997, Q9998, J0901 are cited as new-to-market and require prior authorization per product line listings.