Prior Authorization Requirements for Pharmacy and Medical Benefit Drugs
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Defines why and how prior authorization (PA) is used for drugs covered under WPS Health Insurance, who performs reviews, and how to obtain PA criteria or assistance. Affects providers, pharmacies, and members whose prescriptions may require PA.
No material clinical or coverage changes in this revision.
Coverage Criteria
General PA coverage criteria
Covered when PA requirements met and medical necessity established
All drugs on the listed require PA and are reviewed by designated reviewers (ESI, CCUM, eviCore, or WPS) depending on benefit/vendor.
General PA and reviewer routing
Coverage and authorization requirements summarized for listed drugs
Reviewer option (ESI option 1, CCUM option 2, eviCore option 3) varies by drug as noted in the listing
Administrative PA and reviewer routing
Covered when prior authorization is obtained and routed to the designated reviewer
No clinical criteria in these chunks; this is routing/administrative guidance.
Prior Authorization and Reviewer Routing
Coverage of drugs listed is managed via prior authorization and routed to specified reviewers
Applies to entries in this excerpt
General PA requirement (excerpt)
Covered when prior authorization is obtained from the designated reviewer for each drug.
Refer to vendor-specific reviewer options; if vendor cannot complete review, escalate to WPS.
General PA requirement
Covered when PA is obtained and routed to the designated reviewer
No clinical indication-specific criteria in this excerpt.
Prior Authorization — Listed Drugs
Drugs listed in this document segment are subject to prior authorization and routed to the reviewer/PBM specified for each drug.
Reviewer contact number 1-800-475-1954 appears for PBM reviewer options.
Prior Authorization Routing Requirement
Covered when prior authorization is obtained and routed to the listed reviewer
If the listed reviewer cannot complete review it should be referred to WPS.
Prior Authorization and Reviewer Assignment
Covered when prior authorization is obtained and routed to the designated reviewer/vendor per the list
Routing determines which vendor completes the PA review; oncology drugs frequently route to eviCore.
Prior authorization is used to confirm that a requested drug meets the payer's medical necessity requirements. Services and treatments deemed experimental, investigational, or unproven under applicable clinical guidelines do not meet medical necessity and will not be covered.
When a group uses a PBM other than Express Scripts (ESI) through WPS, providers must follow that PBM's own prior authorization processes and submission requirements. The document repeatedly instructs: If using a PBM other than Express Scripts (ESI) through WPS, refer to the other PBM for PA handling and routing.
For entries routed to vendors other than ESI (for example CCUM or eviCore) the instruction is the same: follow the other PBM/vendor's processes. Where a different PBM is responsible, PA submission, clinical documentation requirements, and reviewer contact should follow that PBM's procedures rather than Express Scripts.
All drugs listed in the excerpt require prior authorization before coverage will be considered. There are no additional clinical coverage criteria included in these specific excerpts; the primary requirement across entries is that a PA be submitted to the designated reviewer for the drug.
Certain agents are routed to specialized management programs. Oncology and gene‑therapy products are frequently routed to eviCore (oncology vendors) or CCUM as indicated in the listing; providers must submit PA requests to the reviewer noted for those programs and follow any eviCore/CCUM routing instructions shown.
If a delegated reviewer (ESI, CCUM, or eviCore) cannot complete the prior‑authorization review, the request should be escalated to WPS for evaluation. The listings repeatedly instruct providers to route requests to WPS when the delegated PBM/vendor is unable to complete the review.
The document states consistently that prior authorization is required for all drugs listed; each PA must be submitted to the reviewer specified for that drug (Express Scripts, CCUM, eviCore) or to WPS if the PBM cannot complete the review. Include required identifiers (e.g., HCPCS/J‑code and drug name) and clinical documentation with the PA submission as directed.
Treatments considered experimental, investigational, or unproven do not meet medical necessity and are therefore not covered. Prior authorization determinations rely on clinical documentation, FDA labeling, and published literature or evidence‑based guidelines to establish whether a requested service meets medical necessity.
Coding (HCPCS / J-codes)
| J3490 | HCPCS Code for 5-fluorouracil topical (as listed) |
| J8499 | HCPCS Code listed for abacavir/dolutegravir/lamivudi |
| J0135 | HCPCS Code for adalimumab |
| J0139 | HCPCS Code for adalimumab |
| J7171 | HCPCS Code for ADAMTS13 recombinant-krhn |
| C9167 | HCPCS Code for ADAMTS13 recombinant-krhn |
| J7207 | antihemo fviii, full length peg |
| J7185 | antihemophil/factor VIII related codes |
| J7192 | antihemophil/factor VIII related codes |
| J7209 | antihemoph:fviii, hek b-delete (NUWIQ) |
| J7210 | antihem.fviii, sin-chn, b-dm tru (AFSTYLA) |
| J9061 | amivantamab-vmjw (RYBREVANT) |
| J0491 | anifrolumab-fnia (SAPHNELO) |
| J0207 | amifostine (ETHYOL) |
| J0257 | alphal-proteinase inhibitor (GLASSIA) |
| J7185 | HCPCS code listed for certain antihemophilic factor products |
| J7192 | HCPCS code listed for certain antihemophilic factor products |
| J7209 | HCPCS code listed (NUWIQ) |
| J7190 | HCPCS code for antihemophilic factor (human) / KOATE family |
| J7182 | HCPCS code for recombinant antihemophilic factor |
| J7211 | HCPCS code listed for recombinant antihemophilic factor |
| J7191 | HCPCS code for some antihemophilic factor/ahf entries |
| J7183 | HCPCS for antihemophilic factor/vwf |
| J7186 | HCPCS for antihemophilic factor/vwf |
| J7187 | HCPCS for antihemophilic factor/vwf |
| J8499 | HCPCS code listed for multiple agents (placeholder non-specific drug code) as shown in document |
| J2782 | HCPCS code for avacincaptad pegol |
| C9162 | Listed alongside J2782 for avacincaptad pegol |
| J0219 | HCPCS code for avalglucosidase alfa-ngpt |
| j8999 | HCPCS miscellaneous code listed for avapritinib oral and other oral oncology agents |
| J3490 | HCPCS unspecified drug code used for multiple topical/injectable agents |
| J9037 | HCPCS code for belantamab mafodotin-blmf |
| J0485 | HCPCS code for belatacept |
| J0490 | HCPCS code for belimumab |
| J9032 | HCPCS code for belinostat |
| J9056 | HCPCS code for bendamustine hcl |
| J9058 | HCPCS code for bendamustine hcl (Apotex) |
| J9059 | HCPCS code for bendamustine hcl (Baxter) |
| J3393 | HCPCS code for betibeglogene autotemcel |
| Q2041 | Code for axicabtagene ciloleucel (CAR-T) |
| J9040 | bleomycin |
| J9041 | bortezomib (Velcade) |
| J9044 | bortezomib alternate |
| J9042 | brentuximab vedotin |
| J1632 | brexanolone |
| C9073 | brexucabtagene autoleucel |
| J8499 | bosentan and many small-molecule entries |
| J9043 | cabazitaxel |
| J0584 | burosumab-twza (CrysVita) |
| J8520 | capecitabine |
| J9047 | carfilzomib |
| J1426 | casimersen |
| C9075 | casimersen |
| Q0240 | casirivimab/imdevimab |
| Q0243 | casirivimab/imdevimab |
| Q0244 | casirivimab/imdevimab |
| J0791 | crizanlizumab-tmca HCPCS code |
| j8999 | crizotinib oral HCPCS code |
| J9145 | daratumumab HCPCS code |
| J9144 | daratumumab and hyaluronidase-fihj HCPCS code |
| J0881 | darbepoetin alfa HCPCS code |
| J0882 | darbepoetin alfa HCPCS code |
| J9011 | datopotamab deruxtecan-dlnk HCPCS code |
| C9174 | datopotamab deruxtecan-dlnk alternate HCPCS/HCPCS-like code |
| J9150 | daunorubicin HCPCS code |
| J9153 | daunorubicin/cytarabine lipos HCPCS code |
| j0589 | daxibotulinumtoxinA-lanm HCPCS code |
| C9160 | daxibotulinumtoxinA-lanm alternate code |
| j8999 | decitabine and cedazuridine oral HCPCS code |
| J8499 | HCPCS code listed for multiple drugs (general drug code placeholder) as provided in document |
| J1413 | delandistrogene moxeparvovec-rokl |
| J0897 | denosumab |
| Q5157 | denosumab-bmwo |
| Q5158 | denosumab-bnht |
| L8605 | dextranomer/hyaluronate/nacl (DEFLUX SOLESTA) |
| J7639 | dornase alfa |
| J9361 | efbemalenograstim alfa-vuxw (biosimilar) HCPCS Code |
| J1449 | eflapegrastim-xnst HCPCS Code |
| J3490 | eladocagene exuparvovec-tneq / elivaldogene autotemcel / eplontersen miscellaneous HCPCS |
| J3590 | eladocagene exuparvovec-tneq / elivaldogene autotemcel / eplontersen miscellaneous HCPCS |
| C9399 | elapegademase-Ivlr / elivaldogene autotemcel / eplontersen unclassified HCPCS |
| C9173 | filgrastim-txid HCPCS (listed) |
| Q5148 | filgrastim-txid HCPCS (listed) |
| J8499 | multiple drugs listed with J8499 as HCPCS |
| J7174 | fitusiran HCPCS |
| J9200 | floxuridine HCPCS |
| J9185 | fludarabine phosphate HCPCS |
| J7311 | fluocinolone acetonide HCPCS |
| S0128 | follistim HCPCS |
| S0126 | follitropin alfa HCPCS |
| J1434 | fosaprepitant HCPCS |
| J1627 | granisetron subcutaneous (SUSTOL) |
| J3490 | granisetron transdermal (SANCUSO), imiquimod |
| J1628 | guselkumab (TREMFYA) |
| J1640 | hemin (PANHEMATIN) |
| J9226 | histrelin acetate |
| J9225 | histrelin implant |
| J1746 | ibalizumab-uiy (TROGARZO) |
| J1744 | icatibant acetate (FIRAZYR / SAJAZIR) |
| J9208 | ifosfamide |
| J1575 | igg/hyaluronidase recombinant (HYQVIA) |
| J8499 | HCPCS code listed for multiple drugs (placeholder for unclassified biologics/other) |
| J9223 | lurbinectedin |
| C9031 | lutetium lu 177 dotatate |
| A9513 | lutetium lu 177 dotatate |
| A9607 | lutetium lu 177 vipivotide tetraxetan |
| A9699 | lutetium lu 177 vipivotide tetraxetan |
| J2182 | mepolizumab |
| J2170 | mecasermin |
| J9250 | methotrexate sodium |
| J9260 | methotrexate sodium |
Provider Actions & Submission Instructions
Prior Authorization Required
Prior Authorization Required — All drugs on this list require prior authorization (PA). Failure to obtain PA may result in denial of coverage. Providers must include the drug name and applicable HCPCS/NDC codes on the PA request.
- All drugs listed require prior authorization (PA).
- Include HCPCS (or NDC where applicable) and the drug name on the PA submission.
Routing and Documentation / Submission Routing and Documentation
Reviewer Routing & Submission Instructions — Submit PA requests to the reviewer indicated for the specific drug (Express Scripts / ESI, CCUM, or eviCore). If the delegated PBM/vendor (ESI, CCUM, or eviCore) cannot complete the review, route the request to WPS for evaluation. For PA or step therapy criteria for drugs reviewed by ESI or CCUM, call 1-800-475-1954. For eviCore clinical guidelines visit https://www.evicore.com/provider/clinical-guidelines and search WPS Health Insurance.
- Submit PA to the reviewer shown for each drug (ESI, CCUM, or eviCore).
- If the PBM/vendor cannot complete the review, direct the request to WPS for evaluation.
- For PA/step therapy details for ESI/CCUM-reviewed drugs call 1-800-475-1954.
- For eviCore clinical criteria: https://www.evicore.com/provider/clinical-guidelines (search WPS Health Insurance)
Medical Necessity and Experimental/Investigational Exclusions
Documentation Considered in PA Review — Medical records documenting the patient’s condition and prior treatments, FDA labeling, published peer-reviewed literature, and evidence-based guidelines will be used in the PA medical necessity determination. Services deemed experimental, investigational, and/or unproven are not covered.
- Medical records describing diagnosis and prior therapies are required.
- FDA-approved labeling, peer-reviewed literature, and evidence-based guidelines will be reviewed.
- Services considered experimental, investigational, or unproven under clinical guidelines are not covered.
Reviewer Routing and HCPCS Codes (examples)
Drug-specific Routing Notes — Certain drugs have specified reviewers and HCPCS codes. Providers must follow the reviewer routing shown for each drug when submitting PA requests.
- Example entries from the drug list: lanadelumab-flyo (HCPCS J0593) — Reviewer: ESI (option 1).
- lanreotide (HCPCS J1930) and lanreotide (cipla) (HCPCS J1932) — Reviewer: CCUM (Non-Oncology, option 2) or eviCore (Oncology, option 3) per comments.
- lapatinib (oral, HCPCS J8999) — Reviewer: eviCore (option 3).
- glofitamab-gxbm (HCPCS J9286) — Reviewer: eviCore (option 3).
Routing Noted; Step Therapy Rules
Routing noted; no step therapy rules in excerpt — Some oncology oral agents and other drugs are routed to eviCore (oncology) versus ESI/CCUM (non-oncology). The excerpt does not contain explicit step therapy rules; contact the reviewer (or 1-800-475-1954 for ESI/CCUM) for step therapy criteria.
- Oncology vs non-oncology routing may determine reviewer (eviCore for oncology).
- No step therapy rules are present in this excerpt — obtain criteria from the designated reviewer.
Escalation when PBM/Vendor Cannot Complete Review
Escalation Path — If the delegated PBM/vendor (ESI, CCUM, or eviCore) cannot complete the prior authorization review, providers must direct the request to WPS for evaluation using the contact information provided on the member’s ID card or 1-800-475-1954 as appropriate.
- When ESI, CCUM, or eviCore cannot complete review, route to WPS for evaluation.
- Use the contact on the member’s insurance card or the general PA line where indicated.
How to Obtain Step Therapy and PA Criteria
How to obtain PA/Step Therapy Criteria — For drugs reviewed by Express Scripts or Care Continuum (CCUM), call 1-800-475-1954 to speak with a prior authorization specialist for detailed PA and step therapy criteria. For eviCore-reviewed drugs, use eviCore’s provider site as noted above. Confirm gene therapy coverage with WPS Customer Service.
- ESI/CCUM PA and step therapy details: 1-800-475-1954.
- eviCore clinical guidelines: https://www.evicore.com/provider/clinical-guidelines.
- Confirm gene therapy coverage with WPS Customer Service via the number on the member’s card.
Initial Therapy Criteria
Initial authorization (administrative)
Administrative: PA required prior to initiation
No clinical initiation criteria provided in these chunks.
lenacapavir initiation requirement
Operational note for lenacapavir initiation
Step Therapy & Prior Authorization Process
| Instruction | Contact / Action |
|---|---|
| For drugs reviewed by Express Scripts or Care Continuum | |
| Call 1-800-475-1954 to speak with a prior authorization specialist to obtain prior authorization and step therapy criteria details. |
| Scenario | Required Provider Action |
|---|---|
| When the member's plan uses a PBM other than Express Scripts (ESI) through WPS | |
| Refer the request to that PBM and follow that PBM's prior authorization processes; if the delegated PBM cannot complete the review route to WPS for evaluation. |
| Observation | Notes from source |
|---|---|
| Some oral oncology and supportive-care agents list different reviewer paths for oncology vs non-oncology | |
| Entries indicate oncology routing to eviCore and non-oncology routing to ESI/CCUM, but no explicit step therapy rules are provided in the excerpt. |
| Coverage requirement | Submission routing |
|---|---|
| Prior authorization required before coverage | |
| Submit prior authorization to the reviewer specified for each drug (ESI, CCUM, or eviCore) as listed in the document. |
| Requirement | Provider action |
|---|---|
| PA required prior to dispensing or administration | |
| Follow the specific reviewer routing shown for each drug entry (ESI, CCUM, or eviCore); include HCPCS/CPT/Q-code and drug name on the PA request. |
| Statement | Implication |
|---|---|
| Step therapy regimens are not listed in this excerpt | |
| No step therapy steps are provided for the drugs shown; contact the reviewer (see routing) for any step therapy details. |
| General rule | Routing / Escalation |
|---|---|
| All listed drugs require prior authorization | |
| Route PA requests to the reviewer assigned per drug (ESI, CCUM, eviCore, or WPS); if the PBM/vendor cannot complete review, direct the request to WPS for evaluation. |
| Routing note | Reviewer assignment |
|---|---|
| Oncology and complex specialty drug requests | |
| Routed to eviCore (option 3) or CCUM (option 2) depending on the drug; if the delegated vendor cannot complete review, escalate to WPS. |
| Summary | Provider responsibility |
|---|---|
| Reviewer assignment varies by drug; prior authorization is required | |
| Submit PA to the assigned reviewer/vendor prior to benefit payment; follow the routing and include required documentation and billing code information. |
Site-of-Care & Benefit Type Notes
Biosimilar Entries & Notes
Background
Prior authorization is used to ensure appropriate use of certain drugs and to determine whether a requested drug meets the payer's medical necessity requirements. The PA review considers medical records, prior treatments, FDA labeling, and peer‑reviewed literature; failure to obtain required PA for any drug on this list may result in denial of coverage.
Definitions & Abbreviations
Revision History
Policy effective date updated to 10/1/2025 as shown in multiple document segments.
Drug listing segments updated to note prior authorization requirement and reviewer routing (ESI, CCUM, eviCore) with the effective date 10/1/2025.
Entries for specific products (e.g., delandistrogene moxeparvovec-rokl, imatinib mesylate, chenodiol, hemin) include reviewer assignments and the instruction to direct reviews to WPS if delegated PBMs cannot complete them, effective 10/1/2025.
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