Drug Prior Authorization List
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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.
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.
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.
Applicable Codes (HCPCS / J / Q / C / S / Other)
| 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) |
| Q5131 | Adalimumab biosimilar (IDACIO) |
| Q5144 | Adalimumab biosimilar (alternate) |
| 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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Operational forms & fax instructions
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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
Effective Date listed as 6/1/2026 in this part (clarified repetition of effective date).
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).
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