January 26, 2021
Page Content Services that require precertification for Medicare Advantage membersAs of January 1, 2021, this list applies to all Independence Blue Cross HMO, POS, and PPO products. This applies to services performed on an elective, nonemergency basis Because a service or item is subject to precertification, it does not guarantee coverage. The terms and conditions of your benefit plan must be reviewed to determine if any of these services or items are excluded. You can find additional information regarding preapproval/precertification, member cost-sharing and prescription drug coverage on the Independence
Preapproval/Precertification Requirements, Member Cost-Sharing, and Prescription Drug Formulary Lists page. All home-care services (including infusion therapy in the home) Inpatient services- Acute rehabilitation admissions
- Elective surgical and nonsurgical inpatient admissions
- Inpatient hospice admissions
- Long term acute care (LTAC) facility admissions
- Skilled nursing facility admissions
Cardiology procedures
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Clinical Appropriateness Guidelines for Cardiology and Arterial Ultrasound, click
here. - Arterial ultrasound
- Diagnostic coronary angiography
- Percutaneous coronary intervention
Any procedure, device, or service that may potentially be considered experimental or investigational including:- New emerging technology/procedures, as well as existing technology and procedures applied for new uses and treatments
Procedures- Bronchial thermoplasty
31660, 31661 - Cochlear implant surgery and associated supplies/bone-anchored (osseointegrated) hearing aids, implantable bone conduction hearing aids
69714, 69715, 69717, 69718, 69930, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693
- Obesity surgery
43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999
- Uvulopalatopharyngoplasty (UPPP)
42145
Musculoskeletal Procedures
Precertification is performed by AIM Specialty Health®, an independent company. For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.
- Bone graft substitutes and bone morphogenetic proteins for spine surgery
- Cervical decompression with or without fusion cervical disc arthroplasty
- Hip arthroplasty
- Hip arthroscopy and open procedures
- Knee arthroplasty
- Knee arthroscopy and open procedures
- Lumbar disc arthroplasty
- Lumbar discectomy, foraminotomy, and laminotomy
- Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)
- Lumbar laminectomy
- Meniscal allograft transplantation of the knee
- Shoulder arthroplasty
- Shoulder arthroscopy and open procedures
- Treatment of osteochondral defects
- Vertebroplasty/Kyphoplasty
Interventional pain management services
Precertification is performed by AIM Specialty Health®, an independent company. For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.
- Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
- Paravertebral Facet Injection/Nerve Block/Neurolysis
- Regional Sympathetic Nerve Block
- Sacroiliac joint injections
- Implanted spinal cord stimulators
Reconstructive procedures and potentially cosmetic procedures- Blepharoplasty/ptosis repair
15820, 15821, 15822, 15823,
67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
- Bone graft, genioplasty and mentoplasty
21120, 21121, 21122, 21123
- Breast Reconstruction
11920, 11921, 11922, 11970, 11971, 15271, 15272, 15769, 15771, 15772, 15773, 15774, 15777, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4100, Q4107, Q4130, S2066, S2067, S2068
- Breast Reduction
15877, 19318
- Breast Augmentation/Mammoplasty
19325
- Breast Mastopexy
19316
- Insertion of Breast Implants
19340, 19342, 19396
- Removal of Breast Implants
19328, 19330, 19370, 19371
- Canthopexy/Canthoplasty
21280, 21282, 67950
- Cervicoplasty
15819 - Chemical peels
15788, 15789, 15792, 15793 - Dermabrasion
15780, 15781, 15782, 15783 - Excision of excessive skin and/or subcutaneous tissue
15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839
- Gender reassignment surgery
11960, 19303, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
- Genetically and bio-engineered skin substitutes for wound care
C1849, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4227, Q4228, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4244, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4254, Q4255
- Hair transplant
15775, 15776 - Injectable dermal fillers
11950, 11951, 11952, 11954, Q2026, Q2028 - Keloid removal
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
- Lipectomy, liposuction, or any other excess fat-removal procedure
15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879
- Otoplasty
13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399
- Rhinoplasty
30400, 30410, 30420, 30430, 30435, 30450 - Rhytidectomy
15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876 - Scar revision
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830 - Skin closures
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770
- Surgery for varicose veins, including perforators and sclerotherapy
36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799
Elective (nonemergency) ground, air, and sea ambulance transportation
A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961
Outpatient private-duty nursing
S9123, S9124
Day rehabilitation programs
0931, 0932
Outpatient radiation therapy
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, click
here. Radiology
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Diagnostic Imaging Utilization Management Clinical Guidelines, click
here.
- CT
- CTA
- Echocardiography services
- Testing transthoracic echocardiography (TTE)
- Stress echocardiography (SE)
- Transesophageal echocardiography (TE)
- MRA
- MRI
- Nuclear cardiology
- PET scans
Prosthetics/orthoses including: - Custom ankle-foot orthoses
L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631 - Custom knee-ankle-foot orthoses
L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128 - Custom knee braces
L1834, L1840, L1844, L1846, L1860
- Custom limb prosthetics including accessories/components
L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6050, L6055, L6100, L6110, L6120, L6130, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7260, L7400, L7401, L7402, L7403, L7404, L7405, L7499
Selected durable medical equipment (DME)- Bone growth stimulators
E0747, E0760 - Bone growth stimulator, electrical, noninvasive, spinal
Precertification is performed by AIM Specialty Health®, an independent company. For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services. - Bone-anchored (osseointegrated) hearing aids
L8690, L8691, L8692, L8693, L8694 - Continuous positive airway pressure (CPAP) devices, bi-level (Bi-PAP) devices, and all supplies
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click here.
- Dynamic adjustable and static progressive stretching devices (excludes CPMs)
E1800, E1802, E1805, E1810, E1812, E1825, E1830 - Electric, power, and motorized wheelchairs including custom accessories
E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294 E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2373, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613 E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630 K0010, K0011, K0012, K0013, K0014, K0056, K0108, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823 K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862 K0863, K0864, K0890, K0891, K0898 - Insulin pumps
E0784, E0787, S1034 - Manual wheelchairs with the exception of those that are rented
E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039 E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110
E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222
E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270
E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608
E2609, E2613,
E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628
E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108 - Negative pressure wound therapy
A6550, A9272, E2402, K0743, K0744, K0745, K0746
- Neuromuscular stimulators
E0744, E0745, E0764, E0770 - Power operated vehicles (POV)
E1230, K0800, K0801, K0802, K0812 - Pressure reducing support surfaces including:
- Non powered advanced pressure reducing mattress
E0371, E0373 - Powered air flotation bed (low air loss therapy)
E0193, E0372 - Powered pressure reducing mattress
E0277
- Push rim activated power assist devices
E0986
- Repair or replacement of all DME items, as well as orthoses and prosthetics that require precertification
E2368, E2369, E2370, E2374, E2375, E2376
- Speech generating devices
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336
Medical foods
B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435
Hyperbaric oxygen therapy
0413, G0277
Proton beam therapy
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, click
here.
Sleep studies (facility based)
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click here.
All transplant procedures, with the exception of corneal transplants
0584T, 0585T, 0586T, 15775, 15776, 27415, 27416, 29866, 29867, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150
Mental health/serious mental illness/substance abuse
Precertification review for these services is provided by Magellan Healthcare, Inc., an independent company.
- Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
- Repetitive transcranial magnetic stimulation (RTMS)
- Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
Autism spectrum disorders
- Applied behavioral analysis
Precertification review for this service is provided by Magellan Healthcare, Inc., an independent company.
Genetic and genomic tests requiring precertification
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, click
here.The following list is a guide to the types of genetic and genomic tests that require precertification. Due to the volume of tests, it is not possible to list each test separately. To determine if a test requires precertification, please see the complete procedure code list for details.
Please note: precertification of genetic and genomic tests applies to commercial members only.
Hereditary cancer syndromes
- BRCA gene testing (breast and ovarian cancer syndrome)
- Lynch syndrome gene testing
- Familial adenomatous polyposis gene testing
- PTEN gene testing (Cowden syndrome)
- General cancer type panels (such as colon, breast, or neuroendocrine cancers)
Hereditary heart diseases
- Long QT syndrome gene testing
- Aortic dilation or aneurysm syndrome testing (includes Marfan syndrome)
Other full gene analysis testing
- Cystic fibrosis full gene sequencing and deletion/duplication analysis
- PMP22 full gene sequencing and deletion/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy)
Tests for many genetic disorders simultaneously - Expanded carrier screening panels (such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening)
- Hearing loss panels
- Intellectual disability panels
- Noonan spectrum disorders panels
Specialty oncology tests- Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™)
- Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others)
- Tissue of origin testing (for cancer of unknown primary)
- PCA3 testing for prostate cancer
Pharmacogenomic tests - Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19)
- Specialized drug response gene panels (such as Assurex GeneSight®, GeneTrait, Genecept®, Millennium PGTSM)
- Warfarin response testing
- MGMT methylation analysis for glioblastoma
Other specialty tests
- Coronary artery disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6)
- Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR)
Genome-wide tests- Microarray studies
- Whole exome testing
- Whole genome testing
- Mitochondrial genome or nuclear testing
ANY genetic test for more than one gene or condition (often includes words like “panel" or “comprehensive" in the name)
ANY genetic test that will be billed with a non-specific procedure code
- Billed with CPT® codes
81400-81408
- Billed with an unlisted code:
81479, 81599, 84999
Specialty drugs requiring precertification
All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change.
Antineoplastic agents- Abraxane® -
J9264
- Adcetris® -
J9042
- Alimta® -
J9305
- Avastin® -
C9257 and J9035
(Note: Opthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Azedra -
A9590
- Azedra Dosimetric -
A9590
- Blenrep -
J3590 and C9069
- Blincyto™ -
J9039
- Cyramza® -
J9308
- Darzalex™ -
J9145
- Darzalex Faspro –
J9144
- Elzonris™ -
J9269
- Enhertu® -
J9358
- Erbitux® -
J9055
- Erwinaze® -
J9019
- Herceptin® -
J9355
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Herceptin® Hylecta -
J9356
- Herzuma -
Q5113
- Instiladrin (pending FDA approval) -
J3490 and C9399
- Kadcyla® -
J9354
- Kanjinti™ -
Q5117
- Kyprolis® -
J9047
- Lumoxiti™ -
J9313
- Margenza™ -
J3490, J3590, and C9399
- Mvasi™ -
Q5107
(Note: Opthalmologic use of Mvasi does not require precertification.)
- Ogivri -
Q5114
- Ontruzant -
Q5112
- Padcev-
J9177
- Pemfexy -
J9304
- Perjeta® -
J9306
- Phesgo –
J9316
- Polivy -
J9309
- Poteligeo® -
J9204
- Provenge® -
Q2043
- Riabni™ -
J3490, J3590, and C9399
- Rituxan® -
J9312
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Rituxan Hycela™ -
J9311
- Ruxience™ -
Q5119
- Sarclisa® -
J9227
- Taclantis™ (pending FDA approval) -
J3490 and C9399
- Tecartus™
(pending FDA approval) –
J3590 and C9073
- Trazimera™ -
Q5116
- Trodelvy™ -
J9317
- Truxima™ -
Q5115
- Xofigo®* -
A9606
- Yervoy™ -
J9228
- Zepzelca –
J9223
- Zevalin®* -
A9543
- Zirabev™ - Q5118
- Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous –
0540T
*
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, click
here.
Anti PD-1/PD-L1 human monoclonal antibodies
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Bavencio® -
J9023
- Dostarlimab
(pending FDA approval) –
J3490,
J3590, and C9399
- Imfinzi™ -
J9173
- Keytruda™ -
J9271
- Libtayo®
- J9119
- Opdivo® -
J9299
- Tecentriq™ -
J9022
Bone-modifying agents- Evenity™ -
J3111
- Prolia® -
J0897
- Xgeva® -
J0897
Botulinum toxin agents Chemotherapy-induced nausea and vomiting (CINV) agents Chimeric antigen receptor (CAR-T) therapies
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Ciltacabtagene Autoleucel
(pending FDA approval) –
J3490,
J3590, and C9399
- Idecabtagene Vicleucel
(pending FDA approval) –
J3490,
J3590, and C9399
- Kymriah™ -
Q2042
- Lisocabtagene maraleucel
(pending FDA approval) -
J3490, J3590, and C9399
- Yescarta™ -
Q2041
Colony stimulating factors - Fulphila™ -
Q5108
- Lapelga
(pending FDA approval) -
J3490, J3590, and C9399
- Neulasta® -
J2505
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Neulasta Onpro™ -
J2505
- Neupogen® -
J1442
- Nivestym™ - Q5110
- Nyvepria™ –
Q5122
- Rolontis® (pending FDA approval) - J3490 and C9399
- Udenyca™ -
Q5111
- Ziextenzo® -
Q5120
Duchenne muscular dystrophy agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Casemirsen
(pending FDA approval) -
J3490, J3590, and C9399
- Viltolarsen
(pending FDA approval) -
J3490, J3590, and C9399
Endocrine/metabolic agents
- Cosyntropin depot
(pending FDA approval) -
J3490, J3590, and C9399
- H.P. Acthar® -
J0800
- Lutathera®* -
A9513 and A9699
- Makena® -
J1726 and J1729
- Sandostatin® LAR -
J2353
- Somatuline® depot -
J1930
*
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, click
here.
Enzyme replacement agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Aldurazyme® -
J1931
- Brineura™ -
J0567
- Cerezyme® -
J1786
- Elaprase® -
J1743
- Elelyso® -
J3060
- Fabrazyme® -
J0180
- Kanuma® -
J2840
- Lumizyme® -
J0221
- Mepsevii™
- J3397
- Naglazyme® -
J1458
- Pegunigalsidase Alfa
(pending FDA approval) –
J3490,
J3590, and C9399
- Replagal®
(pending FDA approval) -
J3490
- Revcovi™
- J3590 and C9399
- Vimizim™ -
J1322
- VPRIV® -
J3385
Gene therapy
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Luxturna™
- J3398
- Valrox (pending FDA approval) - J3490 and C9399
- Zolgensma®
- J3399
- Zynteglo
(pending FDA approval) - J3490, J3590, and C9399
Hemophilia/Coagulation factors
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Advate -
J7192
- Adynovate -
J7207
- Afstyla -
J7210
- Alphanate -
J7186
- Alphanine SD -
J7193
- Alprolix -
J7201
- Autoplex T -
J7198
- Bebulin VH -
J7194
- Bebulin -
J7194
- Benefix -
J7195
- Bioclate -
J7192
- Coagadex -
J7175
- Corifact -
J7180
- Eloctate -
J7205
- Esperoct-
J7204
- Feiba NF -
J7198
- Feiba VH -
J7198
- Fibryga -
J7177
- Fibryna -
J7178
- Helixate FS -
J7192
- Hemlibra -
J7170
- Hemofil-M -
J7190
- Humate-P -
J7187
- Hyate-C -
J7191
- Idelvion -
J7202
- Ixinity -
J7199
- Jivi® -
J7199 and J7208
- Koate-DV I-
J7190
- Kogenate FS -
J7192
- Kovaltry -
J7207 and J7211
- Monarc -
J7190
- Monoclate-P -
J7190
- Mononine -
J7193
- Novoeight -
J7182
- Novoseven RT -
J7189
- Novoseven -
J7189
- Nuwiq -
J7209
- Obizur -
J7188
- Profilnine SD -
J7194
- Proplex T -
J7194
- Rebinyn -
J7203
- Recombinate -
J7192
- Refacto -
J7192
- RiaSTAP -
J7178
- Rixubis -
J7195 and J7200
- Sevenfact -
J7212
- Tretten -
J7181
- Vonvendi -
J7179 and J7199
- Wilate -
J7183
- Xyntha -
J7185
Hyaluronate acid products- Cingal
(pending FDA approval) -
J3490
- Durolane®
- J7318
- Euflexxa™ -
J7323
- Gel-One® -
J7326
- Gelsyn-3™ -
J7328
- GenVisc 850® -
J7320
- Hyalgan® -
J7321
- Hymovis® -
J7322
- Supartz® -
J7321
- Synojoynt -
J7331
- Triluron -
J7332
- TriVisc™ -
J7329
- VISCO-3® -
J7333
Immunological agents- Actemra® -
J3262
- Avsola™ -
Q5121
- Benlysta® -
J0490
- Entyvio™ -
J3380
- Ilumya™ -
J3245
- Inflectra™ -
Q5103
- Ixifi™ -
Q5109
- Orencia® -
J0129
- Remicade® -
J1745
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Renflexis™ -
Q5104
- Simponi® Aria -
J1602
- Stelara® - J3357 and J335
Intravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Intravenous Immune Globulin (IVIG)
- Asceniv -
J1599 and C9072
- Bivigam -
J1556
- Carimune -
J1566
- Flebogamma -
J1572
- Flebogamma-Dif -
J1572
- Gammagard -
J1569
- Gammagard Liquid -
J1569
- Gammagard S/D -
J1566
- Gammaked -
J1561
- Gammaplex -
J1557
- Gamunex-C -
J1561
- Octagam -
J1568
- Panzyga -
J1599
- Privigen -
J1459
- Subcutaneous Immune Globulin (SCIG)
- Cutaquig -
J7799
- Cuvitru -
J1555
- Hizentra -
J1559
- Hyqvia -
J1575
- Xembify -
J1558
Multiple sclerosis agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Lemtrada® -
J0202
- Ocrevus™ -
J2350
- Tysabri® -
J2323
Ophthalmic agents- Abicipar
(pending FDA approval) -
J3490, J3590, and C9399
- Beovu® -
J0179
- Eylea® -
J0178
- Lucentis® -
J2778
- Macugen® -
J2503
- Ranibizumab Biosimilar
(pending FDA approval) –
J3490,
J3590, and C9399
- Tepezza® -
J3241
Pulmonary arterial hypertension
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Flolan® -
J1325
- Remodulin® -
J3285
- Revatio® -
J3490 and C9399
- Trevyent (pending FDA approval) -
J3490 and C9399
- Tyvaso® -
J7686
- Veletri® -
J1325
- Ventavis® -
Q4074
Respiratory agents- Cinqair® -
J2786
- Fasenra™ -
J0517
- Nucala® -
J2182
- Synagis® -
90378
- Xolair® -
J2357
Respiratory enzymes (Alpha-1 antitrypsin)
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Aralast -
J0256
- Glassia™ -
J0257
- Prolastin® -
J0256
- Zemaira® -
J0256
Miscellaneous therapeutic agents- Adakveo® -
J0791
- Ampligen®
(pending FDA approval) -
J3490
- Crysvita - J0584
- Evianacumab
(pending FDA approval) –
J3490,
J3590, and C9399
- Exenatide sustained-release ITCA 650
(pending FDA approval) - J3490
- Gamifant® -
J9210
- Givlaari -
J0223
- Ilaris
- J0638
- Inclisiran
(pending FDA approval) –
J3490,
J3590, and C9399
- Inebilizumab (pending FDA approval)
- J3490 and C9399
- Krystexxa
- J2507
- Onpattro® -
J0222
- Oxlumo™ –
J3490,
J3590, and C9399
- Radicava
- J1301
- Reblozyl® -
J0896
- Remune
(pending FDA approval) -
J3490
- Rethymic™ (RVT-802)
(pending FDA approval) -
J3490, J3590, and C9399
- Soliris® -
J1300
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Spinraza -
J2326
- Trogarzo
- J1746
- Ultomiris™ -
J1303
- Uplizna
– J1823
- Vyepti™ -
J3032
- Xiaflex® –
J0775
Revisions
January 1, 2021 The following revisions were incorporated into the January 1, 2021 update.
Additions, services The entire section entitled
Genetic and genomic tests requiring precertification has been added.
Additions, drugs added Antineoplastic agents- Margenza™ - J3490, J3590, and C9399
- Riabni™ - J3490, J3590, and C9399
- Tecartus™
(pending FDA approval) – J3590 and C9073
- Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T
Anti PD-1/PD-L1 human monoclonal antibodies- Dostarlimab
(pending FDA approval) – J3490, J3590, and C9399
Chimeric antigen receptor (CAR-T) therapies- Ciltacabtagene Autoleucel
(pending FDA approval) – J3490, J3590, and C9399
- Idecabtagene Vicleucel
(pending FDA approval) – J3490, J3590, and C9399
Colony stimulating factors- Neupogen® - J1442
- Nyvepria™ – Q5122
Enzyme replacement agents- Pegunigalsidase Alfa
(pending FDA approval) – J3490, J3590, and C9399
Ophthalmic agents- Ranibizumab Biosimilar
(pending FDA approval) – J3490, J3590, and C9399
Miscellaneous therapeutic agents- Evianacumab
(pending FDA approval) – J3490, J3590, and C9399
- Inclisiran
(pending FDA approval) – J3490, J3590, and C9399
- Oxlumo™ – J3490, J3590, and C9399
- Xiaflex® – J0775
Additions, codes added
Antineoplastic agents- Blenrep – C9069
- Darzalex Faspro – J9144
- Phesgo – J3590 and C9399
- Trodelvy™ - J9317
- Zepzelca™ - J9223
Hemophilia/Coagulation factorsIntravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)Miscellaneous therapeutic agents
Additions, language added
Antineoplastic agents- Instiladrin – (pending FDA approval)
- Taclantis™ – (pending FDA approval)
Colony stimulating factors- Rolontis® – (pending FDA approval)
Duchenne muscular dystrophy agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Gene therapy- Valrox – (pending FDA approval)
Pulmonary arterial hypertension
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Trevyent – (pending FDA approval)
Miscellaneous therapeutic agents- Inebilizumab – (pending FDA approval)
_________________________________________________________________________
Deletions, drugs removed
Antineoplastic agents- Halaven® – J9719
- Jevtana® – J9043
- Margetuximab
(pending FDA approval) - J3490, J3590, and C9399
Duchenne muscular dystrophy agents- Exondys-51™ – J1428
- Vyondys 53 – J1429
Miscellaneous therapeutic agents- Ravulizumab – J3490
- Sylvant™ – J2860
Deletions, codes removed
Reconstructive procedures and potentially cosmetic procedures- Breast Reconstruction – 19366
- Breast Augmentation/Mammoplasty – 19324
Antineoplastic agents- Blenrep – C9399
- Darzalex Faspro – C9062
- Phesgo – J9316 and C9399
- Trodelvy™ – J3590 and C9066
- Zepzelca™ – J3490 and C9399
Hemophilia/Coagulation factors
Miscellaneous therapeutic agents- Uplizna – J3490 and C9399
Deletions, language removed
Ophthalmic agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
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