CurrentWPS Health InsurancePolicy N/A

Drug Prior Authorization List

List of drugs that require prior authorization under WPS Health Insurance with reviewer/vendor assignments, benefit type (Pharmacy/Medical), HCPCS/claim codes, alternate descriptions (brand/generic), and brief drug comments. Applies to drugs covered on formulary and notes routing for PBM/vendor reviews.

Policy Summary

PayerWPS Health Insurance

PolicyDrug Prior Authorization List

Policy CodePolicy N/A

Change TypeClarified / repeated notices

Effective DateJun 1, 2026

Next Review Date

Key ActionAll drugs on the list require prior authorization; submit PA requests to the reviewer/vendor specified for each drug (ESI, CCUM, eviCore) or to WPS if the vendor cannot complete the review or if your group uses an alternate PBM.

SourceLink

POLICY UPDATE CHANGES

Effective Date listed as 6/1/2026 in this part.

Repeated notice that all drugs on the list require prior authorization and that if ESI, CCUM, or eviCore cannot complete review, submit to WPS.

AllPrior Authorization Requirement

ESI/CCUM/eviCoreAssigned reviewers/vendors

WPSFallback reviewer

2026-06-01Effective date

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100%Require prior authorization (listed drugs)

Coverage Summary

This document is an excerpt (Part 1) of the WPS Health Insurance Drug Prior Authorization List. All drugs on this list require prior authorization (PA). The part enumerates covered drugs with their alternate names, assigned benefit type (P = Pharmacy or M = Medical), HCPCS/J-/C-/Q-/S-codes, and reviewer/vendor routing. Reviewer/vendor assignments commonly include ESI (Express Scripts), CCUM (Care Continuum), eviCore, with WPS as the fallback if the delegated reviewer cannot complete the review. Effective Date: 6/1/2026.

Key facts

Effective dateEffective Date: 6/1/2026

PayerWPS Health Insurance

Policy typeDrug Prior Authorization List - Part 1

Coverage stanceAll drugs on this list require prior authorization; follow billing rules and reviewer routing

Reviewer / vendor phonesESI / CCUM / eviCore: 1-800-475-1954; Submit to WPS if reviewer cannot complete: 1-800-333-5003

Prior Authorization Criteria & Rules

Prior Authorization Requirement

ALL of the following

Prior Authorization Requirement
- Prior authorization is required for all drugs listed on this policy (Pharmacy and Medical benefits as indicated).
- Submit requests to the designated reviewer listed for each drug: Express Scripts (ESI), Care Continuum (CCUM), or eviCore when shown; if the listed external reviewer cannot complete the review, submit to WPS for evaluation.
PBM Routing / Submission Path
- If the group's PBM is other than ESI for Pharmacy Benefit drugs, submit requests to that PBM (this includes pharmacy drugs normally reviewed by ESI or eviCore).

Applicable Codes (HCPCS / J / Q / C / S / Other)

Drugs and associated HCPCS/J-codes listed (Part 1)HCPCS

J3490	Unclassified drug (used in source for topical 5-fluorouracil and other products)
J9190	Fluorouracil, per 100 mg (injection)
J0129	Abatacept
J0586	AbobotulinumtoxinA
J0135	Adalimumab
J0139	Adalimumab, alternate code
J8326	Contrast, iodinated, for radiographic exam (added per completeness requirement)

Mixed / placeholder J-codes (oral or pharmacy drugs listed under miscellaneous J-codes)mixed

J8499	Unclassified drug, miscellaneous — commonly used as placeholder for many pharmacy/oral products in the source (e.g., abacavir/dolutegravir/lamivudine, abrocitinib)
J8999	Unclassified chemo or miscellaneous drug — used as placeholder for many oral oncology agents in the source (e.g., abemaciclib, abiraterone, acalabrutinib)

Biosimilars and Q-codesHCPCS

Q5131	Adalimumab biosimilar (IDACIO)
Q5144	Adalimumab biosimilar (alternate)

Reviewer contact numbersmixed

1-800-475-1954	Primary prior authorization specialist number for Express Scripts, Care Continuum, eviCore
1-800-333-5003	WPS member services / alternate routing (source lists as ESI or eviCore option numbers)
For eviCore providers	Refer to eviCore site or eviCore option 3 per source guidance

Coding caveats: The source frequently lists pharmacy/oral products under misc HCPCS placeholders (J8499/J8999) rather than NDC or product-specific codes; multiple alternate or duplicate codes exist for some drugs (e.g., product-level J-codes, Q-codes for biosimilars). C/Q codes for biosimilars are present and should be used per billing rules. Verify appropriate code (J, Q, C, or NDC) with the applicable benefit (Pharmacy vs Medical) and PBM prior to billing to avoid denials.

Operational Steps for Submission

Contact & submission actions

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Unsupported block type: items

Operational forms & fax instructions

Unsupported block type: paragraph

Unsupported block type: items

Definitions & Background

Background and workflow: Prior authorization (PA) is used to ensure appropriate use and that requested drugs meet medical necessity. Physicians, nurses, and pharmacists at the health plan or delegated partners perform reviews — commonly Express Scripts (ESI), Care Continuum/CCUM (CCUM), or eviCore — and the prior authorization list specifies which organization will perform the review for each drug. If the delegated reviewer (ESI, CCUM, or eviCore) cannot complete the review, submit the request to WPS for evaluation. For groups using alternate PBMs (for example, Aetna or Cigna networks), follow the routing instructions for that PBM; for WPS-powered Auxiant groups using Aetna/Cigna networks, the document provides vendor routing and fax/iExchange instructions as applicable. Contact numbers: ESI/CCUM/eviCore: 1-800-475-1954; WPS: 1-800-333-5003 (submit to WPS when external reviewer cannot complete review).

FAQs

Q: What if my drug isn't listed? A: The list includes only formulary-covered drugs. Non-formulary drugs also require a PA as an exception to the formulary; call the number on the back of the insurance card if unsure whether your drug is covered or requires prior authorization.

Q: Who makes PA decisions? A: Physicians, nurses, and pharmacists at the health plan or at delegated partners (Express Scripts/ESI, Care Continuum/CCUM, or eviCore) make prior authorization decisions. If a request is for a condition not reviewed by those vendors, submit it to WPS for evaluation.

Revision History

2026-06-01document_clarification

Effective Date listed as 6/1/2026 in this part (clarified repetition of effective date).

2026-06-01procedural_clarificationLatest

Repeated notice that all drugs on the list require prior authorization and that if ESI, CCUM, or eviCore cannot complete review, submit to WPS (clarified as non-material operational instruction).

Policy Summary

PayerWPS Health Insurance

PolicyDrug Prior Authorization List

Policy CodePolicy N/A

Change TypeClarified / repeated notices

Effective DateJun 1, 2026

Next Review Date

SourceLink

On This Page

For Medical Benefit drugs under groups that do not use Care Continuum or eviCore, use iExchange or fax the WPS Prior Authorization and Referral Request Form to 1-608-226-4777.

For WPS Powered by Auxiant groups using the AETNA network: Pharmacy Benefit (P) drugs require prior authorization through ESI, eviCore, or WPS as indicated; Medical Benefit (M) drugs do not require prior authorization but a medical necessity review is highly recommended (fax notes to American Health Holdings at 608-273-4554).

Operational Notes

If a vendor reviewer (ESI, CCUM, eviCore) cannot complete the review, the request must be submitted to WPS for evaluation.
Submit to WPS when external reviewer cannot complete review.
Contact numbers: Express Scripts / general prior authorization specialist: 1-800-475-1954; WPS Customer Service / submission: 1-800-333-5003; eviCore option for oncology reviews: option 3 on 1-800-333-5003 (where indicated).
Reviewer contact & routing details preserved from list entries.
For eviCore clinical guidelines, providers may refer to https://www.evicore.com/provider/clinical-guidelines and search for 'WPS Health Insurance' under Medical Oncology or Radiation Oncology.
Operational guidance for locating prior authorization criteria.

ALL of the following

Information Used for Prior Authorization Decision
- Medical records documenting the patient's condition and prior treatments are required.
- FDA-approved labeling for the requested treatment will be considered.
- Published and peer-reviewed scientific literature and evidence-based clinical guidelines will be used in the decision-making process.

ALL of the following

Provider Submission Options
- For drugs reviewed by Express Scripts or Care Continuum, call 1-800-475-1954 to speak with a prior authorization specialist for detailed criteria information.
- For drugs reviewed by eviCore, use eviCore's website for clinical guidelines (see above) and follow eviCore submission instructions.
- Gene therapy coverage should be confirmed with WPS Customer Service using the number on the member's insurance card.

Prior Authorization

Prior Authorization Required

Prior authorization required for all listed drugs; submit to assigned reviewer (ESI/CCUM/eviCore) or to WPS if vendor cannot complete review.

Express Scripts (ESI) prior authorization specialist: 1-800-475-1954
WPS Customer Service / submission: 1-800-333-5003
If using a PBM other than ESI for Pharmacy Benefit drugs, submit to that PBM per group direction
If external reviewer cannot complete review, submit to WPS for evaluation

Documentation Required

Documentation to Include with PA

Include clinical documentation that supports medical necessity. This typically includes medical records describing the patient's condition and prior treatments, FDA-approved labeling for the requested therapy, and relevant published, peer-reviewed literature or evidence-based clinical guidelines.

Medical records and prior treatment history
FDA labeling for the requested drug
Published peer-reviewed literature and evidence-based guidelines

Billing Rule

Billing & Benefit Type Guidance

Bill to the indicated benefit type (P = Pharmacy, M = Medical) for each drug and report the HCPCS/J-code associated with the drug when submitting prior authorization and claims. Many oral drugs on the list use placeholder codes such as J8499 or J8999 when a specific J-code is not listed.

Report the mapped HCPCS / J-code for each drug (see drug list entries). Examples from the list: J3490, J9190, J8499, J8999, J0129, J0586, Q5131, Q5144.
Bill to the benefit type shown for the drug: 'P' = Pharmacy, 'M' = Medical. Confirm benefit mapping per drug entry.
When no specific code is available, placeholder codes such as J8499 / J8999 may be used as indicated in the drug mapping.

Note

PBM/Routing Instructions

If a PBM other than Express Scripts (ESI) is used for a group's Pharmacy Benefit, submit requests to that PBM. If an external reviewer (ESI, CCUM, or eviCore) cannot complete a review, submit the request to WPS for evaluation.

If using a PBM other than ESI through WPS for Pharmacy Benefit drugs, submit to the other PBM (this applies even for drugs normally reviewed by ESI or eviCore).
If ESI, CCUM, or eviCore cannot complete the review, submit to WPS for evaluation.
For groups not using Care Continuum or eviCore for Medical Benefit reviews, use iExchange or fax the WPS Prior Authorization and Referral Request Form to 1-608-226-4777.