Why do some drugs require prior authorization
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Describes why certain drugs require prior authorization, who performs reviews, where to get criteria, and provides a list of drugs requiring PA for WPS Health Insurance members and delegated vendors.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage stance
Covered when medical necessity is met and prior authorization is approved
Services deemed experimental, investigational, or unproven per clinical guidelines are not covered. If delegated reviewers (ESI, CCUM, eviCore) cannot complete the review, submit to WPS; if the group uses a different PBM, submit to that PBM.
Initial coverage requirement
Covered only with prior authorization when submitted to designated reviewer
Per‑drug entries include benefit type, HCPCS/J‑codes, and the designated reviewer; no clinical entry‑level criteria are provided in these chunks.
General PA requirement
Covered only with prior authorization
Reviewer routing (ESI, CCUM, eviCore) or submission to WPS is specified per drug entry; if delegated reviewers cannot complete the review, submit to WPS.
Prior Authorization Requirement
Covered when PA obtained
If the delegated reviewer (ESI, CCUM, or eviCore) cannot complete the review, submit to WPS; if using a PBM other than ESI through WPS, submit to that PBM.
General PA coverage condition
Covered when prior authorization is obtained and the request is reviewed by the designated reviewer
Reviewer mapping and HCPCS codes are provided per drug entry; if the PBM/reviewer cannot complete review submit to WPS for evaluation.
General PA coverage criteria (administrative — per-drug)
Covered when PA is approved by the designated reviewer
Document shows per‑drug reviewer assignments and comments (e.g., Oncology, MH/SUD) which should be included with the submission.
General PA requirement and reviewer routing
Covered only with prior authorization when routed appropriately
Applies across the list; each drug line item lists the designated reviewer inline.
Services determined to be experimental, investigational, or unproven under the clinical guidelines are excluded from coverage and will not be covered.
The provided document excerpts do not list any specific drug-level exclusions beyond the general noncoverage of services deemed experimental, investigational, or unproven; this portion functions as a roster of drugs requiring prior authorization rather than an exclusions list.
All drugs on the list require prior authorization and must be submitted to the designated reviewer (ESI, CCUM, or eviCore). If the delegated reviewer cannot complete the review, providers should submit the PA request to WPS for evaluation; no state-specific exclusions are specified in the cited excerpts.
These chunks do not contain drug-specific clinical coverage criteria or decision logic. They serve as an index mapping each listed drug to its benefit type, HCPCS/J-code (where provided), and assigned reviewer; clinical determination and coverage decisions are performed via the prior authorization process by the designated reviewer.
No explicit clinical exclusions are provided in these excerpts. Some entries include a benefit-type flag (P = Pharmacy, M = Medical) and a reviewer assignment (ESI, CCUM, eviCore, or WPS), but the document portion does not enumerate indication-specific exclusions.
The excerpts show that every drug on the roster requires prior authorization; no clinical exclusions are listed in this window. Reviewer routing (ESI for non‑oncology, eviCore for oncology, CCUM as indicated) and the policy effective date are provided, but not indication-level exclusion rules.
In the material shown, the file indicates that all drugs listed require prior authorization; it does not provide explicit clinical exclusion criteria within these chunks.
These excerpts reiterate that listed drugs require prior authorization and include reviewer routing and benefit-type flags, but they do not specify clinical exclusion conditions or coverage exceptions.
No explicit clinical coverage exclusions are stated in these chunks; the content focuses on per‑drug PA requirements, billing codes, and assigned reviewers rather than on conditions that would exclude coverage.
Within this excerpt there are no clinical exclusions listed for the drugs. The document consistently requires prior authorization and specifies reviewer routing, but does not list indication-specific exclusions here.
These chunks again show the PA requirement for all listed drugs and include HCPCS/J-codes and reviewer assignments; they do not state explicit coverage exclusions or clinical criteria that would deny coverage beyond the general noncoverage of investigational services.
No indication-specific exclusion conditions are provided in the cited excerpts. The document portion functions as a PA-required drug list with routing information rather than an exclusions table.
The provided material focuses on listing drugs that require prior authorization and indicating reviewer routing; it does not include explicit clinical exclusions in these excerpts.
Coding and Billing Codes
| J3490 | Listed as HCPCS for multiple topical and pharmacy drugs (e.g., 5-fluorouracil - topical, adapalene/benzoyl peroxide) |
| J9190 | 5-fluorouracil - injection |
| J0129 | Abatacept |
| J8999 | Multiple oral oncology agents (e.g., abemaciclib, afatinib) |
| J9354 | ado-trastuzumab emtansine |
| J0172 | aducanumab-avwa |
| J7352 | afamelanotide acetate |
| Q2057 | afamitresgene autoleucel |
| J0177 | aflibercept (HD) |
| J0178 | aflibercept (HD) |
| Q2057 | afamitresgene autoleucel HCPCS Code (as listed) |
| J0177 | aflibercept (HD) HCPCS Code |
| J0178 | aflibercept (HD) HCPCS Code |
| C9161 | aflibercept-abzv HCPCS Code |
| Q5149 | aflibercept-abzv / various biosimilars HCPCS Code |
| Q5147 | aflibercept-ayyh HCPCS Code |
| Q5170 | aflibercept-boav HCPCS Code |
| Q5155 | aflibercept-jbvf HCPCS Code |
| Q5150 | aflibercept-mrbb HCPCS Code |
| Q5153 | aflibercept-yszy HCPCS Code |
| J3590 | listed for apremilast (example) |
| C9145 | listed for aprepitant - IV |
| J8502 | listed for aprepitant - IV |
| J8501 | listed for aprepitant - oral |
| J8499 | multiple oral/injectable drugs (general HCPCS mapping) |
| J9017 | arsenic trioxide |
| J9022 | atezolizumab |
| J9024 | atezolizumab and hyaluronidase-tqjs |
| J2782 | avacincaptad pegol |
| C9162 | avacincaptad pegol |
| J9075 | cyclophosphamide - inj |
| J9071 | cyclophosphamide - inj (auromedic) |
| J9076 | cyclophosphamide - inj (baxter) |
| J9072 | cyclophosphamide - inj (dr reddy's) |
| J9073 | cyclophosphamide - inj (ingenus) |
| J9074 | cyclophosphamide - inj (sandoz) |
| J8499 | cysteamine bitartrate / many other pharmacy agents |
| J9100 | cytarabine |
| J0850 | cytomegalovirus immune globulin (CYTOGAM) |
| J8999 | dabrafenib - oral and other oral oncologic agents |
| J1301 | HCPCS code listed for edaravone |
| J9334 | HCPCS code listed for efgartigimod alfa and hyaluronidase- |
| J9332 | HCPCS code listed for efgartigimod alfa-fcab |
| J1449 | HCPCS code appearing with eflapegrastim-xnst and related agents |
| J3490 | Miscellaneous HCPCS code appearing with gene therapies and other |
| J3590 | Miscellaneous HCPCS code appearing with gene therapies and other |
| C9399 | Not otherwise classified drug code shown for several products |
| J1322 | HCPCS code listed for elosulfase alfa |
| J9176 | HCPCS code listed for elotuzumab |
| J7170 | HCPCS code listed for emicizumab-kxwh |
| J1786 | imiglucerase |
| J3490 | imiquimod (listed under J3490) |
| J1572 | imm glob g (igg)/sorb/iga 0-50 (FLEBOGAMMA) |
| J1562 | imm glob sc/scig/igsc (VIVAGLOBIN) |
| J1557 | immun glob g(igg)/gly/iga 0-50 (GAMMAPLEX) |
| J1555 | immun glob g(igg)/gly/iga ov50 (CUVITRU) |
| J1556 | immun glob g(igg)/gly/iga ov50 (BIVIGAM) |
| J1569 | GAMMAGARD LIQUID |
| J1459 | immun glob g(igg)/pro/iga 0-50 (PRIVIGEN) |
| J1559 | HIZENTRA |
| J2860 | siltuximab (example from list) |
| J8499 | Multiple oral/IV drugs listed with J8499 as billing code placeholder |
| J3490 | Multiple entries use J3490 |
| J9249 | Example — various J-codes shown across list (specific codes per drug vary) |
| J3241 | Example code present for teprotumumab-trbw |
| J9274 | Example code present for teclistamab-cqyv |
| Q2042 | CAR-T therapy code (tisagenlecleucel) |
| J3055 | Code listed for talquetamab-tgvs |
| J1302 | Code listed for sutimlimab - jome |
| J9331 | Code listed for sirolimus protein-bound particles (FYARRO) |
| J3240 | Code listed for thyrotropin alfa (THYROGEN) |
| J3380 | listed for vedolizumab |
| J3385 | listed for velaglucerase alfa / velmanase alfa |
| J0217 | listed for velmanase alfa |
| J8999 | multiple oral/oncolytic/other drugs |
| J8499 | multiple drugs (e.g., vigabatrin, vibegron, vortioxetine) |
| J3396 | listed for verteporfin |
| J3397 | listed for vestronidase alfa-vjbk |
| J9360 | listed for vinblastine sulfate |
| J9370 | listed for vincristine sulfate |
| J9390 | listed for vinorelbine tartrate |
Provider Actions and Submission Requirements
Prior authorization required for all listed drugs
All drugs shown on the PA roster require prior authorization; if delegated reviewers (ESI, CCUM, or eviCore) cannot complete the review, submit the request to WPS (or to the PBM used by the group when different from ESI).
- PLEASE NOTE: All drugs on this list require a PA.
- If ESI, CCUM, or eviCore cannot complete the review, submit to WPS for evaluation.
- If using a PBM other than ESI through WPS, submit to that PBM.
Submit PA to the designated reviewer listed per drug
Prior authorization must be submitted to the reviewer designated in the drug entry (ESI, CCUM, eviCore, or WPS). Use the reviewer assigned for each line item when routing PA requests.
- Description field 4 = Reviewer (ESI, CCUM, eviCore or WPS) and must be used for submission.
- Reviewer options: ESI (option 1), CCUM (option 2), eviCore (option 3); WPS is the fallback when external reviewers cannot complete review.
Obtain PA for every drug on the list (per-drug routing)
A prior authorization is required for any drug that appears on this list; each drug entry specifies benefit type and billing code(s) and identifies the reviewer to receive the PA.
- Each line includes: Alt Descriptions; Benefit Type (P = Pharmacy, M = Medical); HCPCS/J-code(s); Reviewer; Drug comments.
- Route the PA to the reviewer shown for that drug.
PA required — use the reviewer indicated per drug
All drugs on the roster require prior authorization; the document lists the specific reviewer (ESI, CCUM, eviCore, or WPS) for each drug and that reviewer must be used unless they cannot complete the review.
- If external reviewer cannot complete review, submit to WPS.
- Benefit type and HCPCS code are shown per-drug and should be included with the PA.
PA required — reviewers identified per drug (contact info provided)
All drugs require prior authorization; reviewer assignments and contact routing (ESI, CCUM, or eviCore) are provided for each entry and must be followed when submitting PA requests.
- Description fields define where to find reviewer and benefit type (Description 2 = Benefit Type; Description 4 = Reviewer).
- Primary contact routing shown; phone numbers for reviewers and WPS are provided in the document.
Include benefit type and HCPCS/J-code and send PA to assigned reviewer
Prior authorization is required for every drug listed; include the drug identifier, benefit type, and HCPCS/J-code(s) as shown on the line item and route the request to the assigned reviewer.
- Provide Alt Descriptions (brand/name), Benefit Type (P or M), HCPCS code, and any Drug Comments when submitting the PA.
- PA submissions should be sent to ESI (option 1), CCUM (option 2), eviCore (option 3), or WPS when external reviewers cannot complete the review.
Route PA to the reviewer shown; submit to WPS if reviewer unavailable
All drugs listed require prior authorization and must be routed to the designated reviewer (ESI, CCUM, eviCore); if those reviewers cannot complete the review, submit to WPS or the PBM used by the group.
- When external reviewers cannot complete a review, WPS is the fallback for evaluation.
- If the group uses a different PBM than ESI through WPS, submit to that PBM for review.
Provide medical records and supporting clinical evidence with PA
Documented sources used in review include the patient’s medical records, FDA-approved labeling, published peer‑reviewed literature, and evidence‑based guidelines; provide these materials as needed when submitting a PA.
- Medical records describing the patient’s condition and prior treatments.
- FDA‑approved labeling and published peer‑reviewed scientific literature or evidence‑based guidelines.
Required submission details: drug ID, benefit type, and HCPCS/J-code
PA submissions must identify the drug (alt description/brand), indicate benefit type (P = Pharmacy or M = Medical), include the applicable HCPCS/J-code(s), and note any drug comments (e.g., Oncology, MH/SUD).
- Description 1 = Alt Descriptions; 2 = Benefit Type; 3 = HCPCS Code; 4 = Reviewer; 5 = Drug Comments.
- Include the HCPCS or other billing code shown on the drug line when submitting the PA.
No PA submitted = risk of denial or non‑processing
If a PA is not obtained for any drug on this list, the claim or drug request may be denied; the document repeatedly warns that failure to submit required prior authorization risks denial.
- PLEASE NOTE: All drugs on this list require a PA.
- Failure to submit PA may result in the drug not being processed under the PA workflow or in denial of coverage.
Submit to the correct designated reviewer (avoid misrouting)
Submit the PA to the reviewer listed in the drug entry (ESI, CCUM, or eviCore); when external reviewers cannot complete the review submit to WPS. Submitting to the wrong reviewer can delay or affect approval.
- Reviewer field (Description 4) indicates the correct reviewer to receive the PA.
- If external reviewer cannot complete the review, submit to WPS for evaluation.
Where to obtain step‑therapy and PA criteria from delegated reviewers
Where step therapy or clinical criteria are managed by delegated vendors, obtain criteria from the vendor: call 1-800-475-1954 for ESI/CCUM or view eviCore clinical guidelines online; confirm gene therapy coverage with WPS Customer Service.
- For ESI or CCUM questions call 1-800-475-1954.
- For eviCore guidelines see https://www.evicore.com/provider/clinical-guidelines and search for 'WPS Health Insurance'.
- Confirm Gene Therapy coverage with WPS Customer Service using the number on the member’s card.
Step therapy not specified in this document — check reviewer guidelines
The document does not specify step‑therapy sequences or required prior failures in the excerpt; providers must rely on the designated reviewer’s clinical guidelines for any step‑therapy requirements.
- No explicit step‑therapy algorithms are provided in these chunks; routing and reviewer assignment are shown instead.
- Delegated reviewers (ESI, CCUM, eviCore) maintain step therapy/criteria and will apply them during review.
Include HCPCS/J/Q code and route PA to the reviewer listed
When submitting a PA, include the drug identifier and the applicable HCPCS/J/Q code(s) as listed on the drug line and route the submission to the reviewer shown (ESI, CCUM, eviCore or WPS).
- Include Alt Descriptions, Benefit Type, HCPCS code, Reviewer, and Drug Comments as provided on the line item.
- Contact numbers for reviewers and WPS are provided in the document for submission routing.
Definitions and Field Mapping
Initial Prior Authorization Metadata
Initial PA metadata (no clinical criteria in excerpt)
Per‑drug PA routing and metadata (no clinical criteria in excerpt)
This section contains administrative metadata used to submit PA requests; clinical necessity criteria are maintained by the designated reviewers and are not present in the provided excerpt.
Step Therapy and Vendor Criteria
| Step therapy summary | Where to obtain details / reviewer | Notes |
|---|---|---|
| Step therapy and prior authorization criteria are maintained by delegated reviewers; this document does not list internal step sequences | ||
| ESI/CCUM: call 1-800-475-1954; eviCore: https://www.evicore.com/provider/clinical-guidelines (search 'WPS Health Insurance') | ||
| Providers should contact the designated reviewer for specific step therapy or clinical-criteria requirements; confirm gene therapy coverage with WPS Customer Service |
| Step therapy present? | Evidence in document | Action for providers |
|---|---|---|
| No — document is a prior authorization (PA) drug list and does not define step edits | ||
| Multiple entries state 'PLEASE NOTE: All drugs on this list require a PA' and list reviewer routing and benefit type but no step rules | ||
| Submit PA to the reviewer listed for the drug (ESI, CCUM, eviCore) or to WPS if reviewers cannot complete review |
| Step-therapy sequences specified? | Reviewer routing shown? | Implication |
|---|---|---|
| No — no step-therapy sequences are specified in these chunks | ||
| Yes — drugs include a 'Reviewer' field indicating ESI (option 1), CCUM (option 2), or eviCore (option 3) as appropriate | ||
| Clinical determinations, including any step-therapy checks, are handled by the assigned reviewer—providers must follow reviewer criteria |
| Document specifies step therapy sequences? | Reviewer assignment examples | Recommended provider step |
|---|---|---|
| No — document routes drugs to external reviewers for clinical determination rather than listing step sequences | ||
| Examples: cabazitaxel → eviCore (option 3); cabotegravir → CCUM (option 2); many oncology agents routed to eviCore | ||
| Submit PA with required clinical documentation to the reviewer listed; follow that reviewer’s clinical guideline for step requirements |
| Benefit type / step therapy detail | Does it list prior failures or steps? | Reviewer implications |
|---|---|---|
| Entries include Benefit Type flags (P = Pharmacy, M = Medical) and reviewer routing metadata | ||
| No — these chunks do not specify required prior failures or explicit step therapy steps | ||
| Benefit-type and reviewer mapping guide where to submit PA; clinical criteria (including steps) are determined by the reviewer |
| Routing options noted | Reviewer option codes | Step-therapy sequencing documented? |
|---|---|---|
| Routing options to different reviewers are provided; document annotates reviewer option numbers per drug | ||
| ESI = option 1; CCUM = option 2; eviCore = option 3; WPS is fallback if reviewer cannot complete review | ||
| No — the document includes routing options but does not specify step-therapy sequencing or required prior failures |
| Route to designated reviewer | PA requirement | Document guidance |
|---|---|---|
| Route PA to the reviewer listed for each drug: ESI, CCUM, eviCore, or WPS as indicated | ||
| All listed drugs require prior authorization before coverage as stated repeatedly in the document | ||
| If delegated reviewers cannot complete review, submit to WPS; if group uses a different PBM, submit to that PBM per instructions |
| Step therapy sequences listed? | PA requirement shown? | Provider take-away |
|---|---|---|
| No — these excerpts do not list step therapy sequences or required prior drug failures | ||
| Yes — the entries show 'All drugs on this list require a PA' and include reviewer routing and benefit type per drug | ||
| Providers must submit PA to the reviewer indicated and follow that reviewer’s clinical guidelines for any step-therapy rules |
| Provider submission requirement | Where to send PA | Step therapy detail availability |
|---|---|---|
| Providers must submit prior authorization requests for listed drugs and include required identifiers (benefit type, HCPCS/J-code where applicable) | ||
| Submit to the assigned reviewer (ESI, CCUM, eviCore) as specified per drug; if reviewer cannot complete the review, submit to WPS; if another PBM is used, submit to that PBM | ||
| Specific step therapy criteria are not included in this list; obtain step therapy/clinical criteria from the delegated reviewer (call 1-800-475-1954 for ESI/CCUM or view eviCore clinical guidelines online) |
Site of Care and Benefit Type Implications
Use provided reviewer contacts for PA submission
Use the reviewer contact and routing information provided in the document: main WPS routing and reviewer phone numbers (e.g., 1‑800‑475‑1954 for ESI/CCUM routing and reviewer contacts) are shown for PA submission questions.
Biosimilars Listed
Background
Prior authorization is used to ensure appropriate use of certain drugs and to confirm that a requested drug meets the plan's medical necessity requirements. Reviewers rely on medical records, FDA‑approved labeling, peer‑reviewed literature, and evidence‑based guidelines when determining coverage. Services deemed experimental, investigational, or unproven under the clinical guidelines are not covered.
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