Commercial

​​​​​​​​Services that require precertification for Independence Commercial Members (Effective 01/01/2022)


Services that require precertification 


​As of January 1, 2022, this list applies to all Independence Blue Cross HMO, PPO, and POS products, including Flex products.  For Federal Employee Program (FEP) precertification requirements, please see the separate FEP precertification list. 

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​ 

  • 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
     

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, Q4116, Q4130, Q4142, Q4143, 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

    A2001, A2002, A2003, A2004, A2007, A2008, A2009, A2010, C1849, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, 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, Q4199, 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, Q4251, Q4252, Q4253, 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, including inpatient hospital-to-hospital transfers


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

    • K1014, K1022, 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

    69716, 69719, 69726, 69727, 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: 
    • Air fluidized bed

      E0194
       
    • 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 

In-Lab / Facility sleep studies


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. 


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. 



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 disease​s


  • 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 simulta​​​neously 


  • 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 spec​​ialty 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 te​​​​​​sts 


  • 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 nam​e) 


ANY genetic test th​at 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 requi​​​ring precert​​ification


All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change. 

Antineoplastic agen​​ts


  • 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
  • Blenrep - J9037
  • Blincyto™ - J9039
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro – J9144
  • 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™ - J9353
  • Monjuvi® - J9349
  • Mvasi™ - Q5107 (Note: Opthalmologic use of Mvasi does not require precertification.)
  • Ogivri - Q5114
  • Ontruzant - Q5112
  • Oportuzumab Monatox (pending FDA approval) - J3490, J3590, and C9399​
  • 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
  • Rybrevant™ - J9061 
  • Rylaze™ - J9021​
  • Sarclisa® - J9227
  • SH-111 (pending FDA approval) - J3490, J3590, and C9399​
  • Taclantis™ (pending FDA approval) - J3490 and C9399
  • Tivdak™ - J3490, J3590, and C9399
  • Trazimera™ - Q5116
  • Trodelvy™ - J9317
  • Truxima™ - Q5115
  • Ublituximab (pending FDA approval) - J3490, J3590, and C9399
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca™ – J9223
  • Zevalin®* - A9543
  • Zirabev™ - Q5118
  • Zynlonta™ J3590 and C9084​

    • * Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore w​​ebsite, 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. 
  • Balstilimab (pending FDA approval) - J3490, J3590, and C9399​
  • Bavencio® - J9023
  • Imfinzi™ - J9173
  • Jemperli™ - J9272
  • Keytruda™ - J9271
  • Libtayo® - J9119
  • Opdivo® - J9299
  • Penpulimab (pending FDA approval) - J3490, J3590, and C9399​
  • ​​​Retifanlimab (pending FDA approval) - J9999 and C9399​
  • ​Sintilimab (pending FDA approval) - J3490, J3590, and C9399​
  • ​Tecentriq™ - J9022 

​​​​Bone-modifying agents 

​

  • Evenity™ - J3111
  • Prolia® - J0897
  • Xgeva® - J0897 

Botulinum toxin agen​​ts 


  • ​Botox® - J0585 

Chemotherapy-induced nau​​sea and vomiting (CINV) agents 


  • Sustol® - J1627 

Chimeric antigen recept​​or (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. 
  • Abecma® - Q2055
  • Breyanzi® - Q2054
  • Ciltacabtagene Autoleucel (pending FDA approval) – J3490, J3590, and C9399​
  • Kymriah™ - Q2042
  • Tecartus™ - Q2053
  • ​Yescarta™ - Q2041
  • Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T​​


Endocrine/metabolic agents

  • Acthar H.P.® - J0800​
  • ​​Cosyntropin depot (pending FDA approval) - J3490, J3590, and C9399​
  • 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
  • ​Cipaglucosidase Alfa (pending FDA approval) – J3490, J3590, and C9399​
  • Elaprase® - J1743
  • Elelyso® - J3060
  • Fabrazyme® - J0180
  • Kanuma® - J2840
  • Lumizyme® - J0221
  • Mepsevii™ - J3397
  • Naglazyme® - J1458
  • ​Nexviazyme™ - C9085​
  • ​Olipudase Alfa (pending FDA approval) - J3490, J3590, and C9399​
  • 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
  • Roctavian (pending FDA approval) - J3490 and C9399​
  • Zolgensma® - J3399
  • ​Zynteglo (pending FDA approval) - J3490, J3590, and C9399 

Hemophil​ia/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
  • Bebulin VH® - J7194
  • Bebulin® - J7194
  • Benefix® - J7195
  • Coagadex® - J7175
  • Corifact® - J7180
  • Eloctate® - J7205
  • Esperoct® - J7204
  • Feiba NF® - J7198
  • Feiba VH® - J7198
  • Fibryga® - J7177
  • Helixate FS® - J7192
  • Hemlibra® - J7170
  • Hemofil-M® - J7190
  • Humate-P® - J7187
  • Idelvion® - J7202
  • Ixinity® - J7199
  • Jivi® - J7199 and J7208
  • Koate-DV I® - J7190
  • Kogenate FS® - J7192
  • Kovaltry® - J7207 and J7211
  • Monarc® - J7190
  • Mononine® - J7193
  • Novoeight® - J7182
  • Novoseven RT® - J7189
  • Novoseven® - J7189
  • Nuwiq® - J7209
  • Obizur® - J7188
  • Profilnine SD® - J7194
  • Rebinyn® - J7203
  • Recombinate® - J7192
  • RiaSTAP® - J7178
  • Rixubis® - J7195 and J7200
  • Sevenfact® – J7212
  • Tretten® - J7181
  • Vonvendi® - J7179 and J7199
  • Wilate® - J7183
  • ​Xyntha® - J7185 

Hyaluronate acid pro​​​ducts


  • 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® - J7321

Immunological a​​​​gents


  • 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
  • Saphnelo™ - C9086​
  • Simponi® Aria - J1602
  • Stelara® - J3357 and J3358  

Intravenous Immune Globulin/Sub​​​cutaneous 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® - J1554
    • Bivigam® - J1556
    • Carimune® - J1566
    • Flebogamma® - J1572
    • Flebogamma-Dif® - J1572
    • 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
    • Xembi​​fy®​ - J1558

 Multiple sclero​sis a​​gents


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 

Neutropenia

  • Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Fulphila™ - Q5108
  • Lapelga (pending FDA approval) - J3490, J3590, and C9399
  • Neulasta® - J2506 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • Neulasta Onpro™ -​ J2506
  • Neupogen® - J1442
  • Nivestym™ - Q5110
  • Nyvepria™ - Q5122
  • Plinabulin (pending FDA approval) - J3490, J3590, and C9399
  • Rolontis® (pending FDA approval) - J3490 and C9399
  • Udenyca™ - Q5111
  • Ziextenzo® - Q5120​


Ophthalm​ic agents 

​

  • Abicipar (pending FDA approval) - J3490, J3590, and C9399
  • Beovu® - J0179
  • ​​Byooviz™ - J3490, J3590, and C9399​
  • Eylea® - J0178
  • Faricimab (pending FDA approval) - J3490, J3590, and C9399
  • Lucentis® - J2778 ​(Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • ​Susvimo™- C1889​
  • ​Tepe​zza® - J3241 

Pulmonary arterial h​​​​ypertension


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 

Respirato​​ry agents​


  • Cinqair® - J2786
  • Synagis® - 90378
  • ​Xolair® - J2357 

Respiratory enzymes (Alpha-1 a​​ntitrypsin)


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 a​​gents 


  • Adakveo® - J0791
  • Ampligen® (pending FDA approval) - J3490
  • Cosela® - J1448
  • Crysvita - J0584
  • Donislecel (pending FDA approval) – J3490, J3590, and C9399​
  • Efgartigimod (pending FDA approval) - C9399 and J3590​
  • Evkeeza™ - J1305
  • Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
  • Gamifant® - J9210
  • Givlaari - J0223
  • Ilaris - J0638
  • Inclisiran (pending FDA approval) – J3490, J3590, and C9399
  • Krystexxa - J2507
  • Narsoplimab (pending FDA approval) - C9399 and J3590​
  • Onpattro® - J0222
  • Oxlumo™ - J0224​
  • Oxlumo™ – J3490, J3590, and C9399
  • Radicava - J1301
  • Reblozyl® - J0896
  • Remune (pending FDA approval) - J3490
  • Rethymic™ - J3490, J3590, and C9399
  • Soliris® - J1300 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Spinraza - J2326
  • Sutimlimab (pending FDA approval) - C9399 and J3590​
  • ​Teplizumab (pending FDA approval) - C9399 and J3590​​
  • Ultomiris™ - J1303
  • Uplizna - J1823
  • ​Vutrisiran (pending FDA approval) - J3490, J3590, and C9399​
  • Vyepti™ - J3032
  • ​Xiaflex® - J0775

Revisio​ns​

​

​​​​​​​​​​​January 1, 2022

 
The following revisions were incorporated into the January 1, 2022 update.

Additions, codes added

​​Genetically and bio-engineered skin substitutes for wound care

A2001, A2002, A2003, A2004, A2007, A2008, A2009, A2010, Q4199


Bone-anchored (osseointegrated) hearing aids

69716, 69719, 69726, 69727


Antineoplastic agents

Monjuvi® - J9349
Oportuzumab Monatox (pending FDA approval) - J3490, J3590, and C9399
Rybrevant™ - J9061
Rylaze™ - J9021
SH-111 (pending FDA approval) - J3490, J3590, and C9399
Tivdak™ - J3490, J3590, and C9399
Ublituximab (pending FDA approval) - J3490, J3590, and C9399


Anti PD-1/PD-L1 human monoclonal antibodies

Balstilimab (pending FDA approval) - J3490, J3590, and C9399
Jemperli™ - J9272
Penpulimab (pending FDA approval) - J3490, J3590, and C9399
Sintilimab (pending FDA approval) - J3490, J3590, and C9399

Chimeric antigen receptor (CAR-T) therapies
Abecma® - Q2055


Enzyme replacement agents

​Cipaglucosidase Alfa (pending FDA approval) – J3490, J3590, and C9399

Nexviazyme™ - C9085
Olipudase Alfa (pending FDA approval) - J3490, J3590, and C9399


Immunological agents

​Saphnelo™ - C9086


Neutropenia

​Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399

Neulasta® - J2506
Neulasta Onpro™ - J2506
Plinabulin (pending FDA approval) - J3490, J3590, and C9399


Ophthalmic agents

​Byooviz™ - J3490, J3590, and C9399

Faricimab (pending FDA approval) - J3490, J3590, and C9399
Susvimo™- C1889


Miscellaneous therapeutic agents

Donislecel (pending FDA approval) – J3490, J3590, and C9399

Vutrisiran (pending FDA approval) - J3490, J3590, and C9399

 ​ _________________________________________________________________________

Deletions, drugs deleted
 

Bronchial thermoplasty
​31660, 31661

 

Uvulopalatopharyngoplasty (UPPP)

42145

 

Antineoplastic agents

Elzonris™ - J9269

Pepaxto® - J9247
Rybrevant™ - J9999 and C9083
 

Anti PD-1/PD-L1 human monoclonal antibodies

Jemperli™ - J3590 and C9082


Chimeric antigen receptor (CAR-T) therapies

Abecma® - J3490, J3590, and C9081
 

Enzyme replacement agents

Avalglucosidase Alfa (pending FDA approval) - C9399 and J3590

Immunological agents

Anifrolumab (pending FDA approval) - C9399 and J3590

Neutropenia

Neulasta® - J2505

Neulasta Onpro™ - J2505


Miscellaneous therapeutic agents

Trogarzo - J1746

 
Changes

The category Sleep studies (facility based) was changed to In-Lab / Facility sleep studies.


Miscellaneous therapeutic agents

Rethymic™ - Removal of (pending FDA approval) indication

The category of specialty drugs previously referred to as “Colony-stimulating factors" has been changed to “Neutropenia".​



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