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​​​​​​​​Services that require precertification for Independence Medicare Advantage Members (Effective 10/01/2023)​

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Services that require precertification for Medicare Advantage members


As of October 1, 2023, 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 Carelon Medical Benefits Management, an independent company.  To access the complete list of Carelon 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 Carelon Medical Benefits Management, 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 Carelon Medical Benefits Management, 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, A2004, A2007, A2008,A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021, A2022, A2023, A2024, A2025, 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, Q4224, Q4225, 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, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4277, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284


  • 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 Carelon Medical Benefits Management, an independent company.  To access the complete list of Carelon 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 Carelon Medical Benefits Management, 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 Carelon Medica Benefits Management, an independent company.  To access the complete list of Carelon Sleep Disorder Management Diagnostic and 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, E2300,
    E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, 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, K0830, K0831, 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 ​- See specific DME, orthoses, and prosthetics categories for Repair or Replacement codes that require precertification.
  • 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 Carelon Medical Benefits Management, an independent company.  To access the complete list of Carelon Sleep Disorder Management Diagnostic and 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


  • 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 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.

Alzheimer's disease agents

  • Aduhelm™ - J0172
  • Donanemab (pending FDA approval) - J3490, J3590 and C9399​​
  • Lecanemab (pending FDA approval) - J3490, J3590 and C9399


Amyotrophic Lateral Sclerosis agents​

  • Radicava™ - J1301
  • Qalsody™– J3490, J3590, and C9399​


Antineoplastic agents

  • Abraxane® - J9264
  • Adstiladrin® - J9029​
  • Adcetris® - J9042
  • Alimta® - J9305
  • Alymsys® - Q5126 (Note: Ophthalmologic use of Alymsys does not require precertification.)​
  • 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
  • Blincyto™ - J9039
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro™ – J9144
  • Elahere™ - J9063​
  • Enhertu® - J9358
  • ​Epkinly™ - C9155​
  • Erbitux® - J9055
  • Erwinaze® - J9019
  • Herceptin® - J9355 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Herceptin® Hylecta - J9356
  • Herzuma® - Q5113
  • Imjudo® - J9347
  • Kadcyla® - J9354
  • Kanjinti™ - Q5117
  • Kimmtrak® - J9274​
  • Kyprolis® - J9047
  • Lumoxiti™ - J9313
  • Lunsumio™ - J9350
  • ​Margenza™ - J9353​
  • ​Monjuvi® - J9349​
  • Mvasi™ - Q5107 (Note: Opthalmologic use of Mvasi does not require precertification.)​
  • Ogivri™ - Q5114
  • Ontruzant® - Q5112
  • Opdualag™ - J9298​
  • Oportuzumab Monatox (pending FDA approval) - J3490, J3590, and C9399
  • Paclitaxel - J9259
  • Padcev-™ J9177
  • Pemetrexed - J9322, J9323​
  • Pemfexy™ - J9304, J9314, J9294, J9296 and J9297​
  • Perjeta® - J9306
  • Phesgo™ – J9316
  • Pluvicto™* - J3490 and C9399
  • Polivy™- J9309
  • Poteligeo® - J9204
  • Provenge® - Q2043
  • Riabni™ - Q5123​
  • 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
  • Tecvayli™ - J9380 
  • Tivdak™ - J9273
  • Trazimera™ - Q5116
  • Trodelvy™ - J9317
  • ​​Truxima™ - Q5115
  • Vegzelma® - Q5129 (Note: Ophthalmologic use of Vegzelma does not require precertification.)
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca™ – J9223
  • Zevalin®* - A9543
  • Zirabev™ - Q5118 (Note: Ophthalmologic use of Zirabev does not require precertification.)​
  • Zynlonta™ J9359
  • Zynyz™ - J9345​

​* 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.
  • 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
  • Sintilimab (pending FDA approval) - J3490, J3590, and C9399
  • Tecentriq™ - J9022
  • Tislelizumab (pending FDA approval) - J3490 and C9399
  • Toripalimab (pending FDA approval) - J3490 and C9399​
  • ​Zynyz™ - J3590 and C9399​


Bone-modifying agents


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


Botulinum toxin agents


  • Botox® - J0585

Chemotherapy-induced nausea and vomiting (CINV) agents


  • Sustol® - J1627

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.
  • Abecma® - Q2055
  • Breyanzi® - Q2054
  • Carvykti™ - Q2056​
  • Kymriah™ - Q2042
  • Tecartus™ - Q2053​
  • ​Yescarta™ - Q2041       
  • Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T​ 


Endocrine/metabolic agents

  • ​Achtar H.P.® - J0801 and J0802​
  • ​Cosyntropin depot (pending FDA approval) - J3490, J3590, and C9399​
  • Ianreotide - J1932 
  • Lutathera®* - A9513 and A9699
  • Makena® - J1726 and J1729
  • Sandostatin® LAR - J2353
  • Somatuline® depot - J1930
  • Xenpozyme™ - J0218​

​​* 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™ - J0219
  • Pegunigalsidase Alfa (pending FDA approval) – J3490, J3590, and C9399
  • Replagal® (pending FDA approval) - J3490
  • Revcovi™ - J3590 and C9399
  • Vimizim™ - J1322
  • VPRIV® - J3385
  • Xenpozyme® - J3590 and C9399​

Gene Replacement / Gene Editing 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.

  • ​Hemgenix® - J1411​
  • Luxturna™ - J3398
  • ​Roctavian™ - J3590 and C9399​
  • Skysona® - J3590 and C9399
  • Vyjuvek™ - J3590 and C9399​
  • Zolgensma® - J3399
  • Zynteglo® - 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
  • Altuviiio™ - J7214​
  • Bebulin VH® - J7194
  • Benefix® - J7195
  • 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
  • Idelvion® - J7202
  • Ixinity® - J7213
  • Jivi® - J7199 and J7208
  • Koate-DVI® - J7190
  • Kogenate FS® - J7192
  • Kovaltry® - J7207 and J7211
  • Monoclate-P® - 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 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® - J7321

Immunological agents


  • Actemra® IV- J3262
  • Avsola™ - Q5121
  • Benlysta® IV- J0490
  • Entyvio™ - J3380
  • Ilumya™ - J3245
  • Inflectra™ - Q5103
  • Infliximab (unbranded) – J1745​
  • Ixifi™ - Q5109
  • Orencia® IV- J0129
  • Remicade® - J1745 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Renflexis™ - Q5104
  • Saphnelo™ - J0491​
  • Simponi® Aria - J1602
  • Skyrizi® IV - J2327
  • Spevigo® - J1747
  • Stelara® - J3357 and J3358

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® - J1554
    • Bivigam® - J1556
    • Flebogamma® - J1572
    • Flebogamma®-Dif - J1572
    • Gammagard® - J1569
    • Gammagard S/D® - J1566
    • Gammaked® - J1561
    • Gammaplex® - J1557
    • Gamunex-C® - J1561
    • Octagam® - J1568
    • Panzyga® - J1576
    • Privigen® - J1459 
  • Subcutaneous Immune Globulin (SCIG)
    • Cutaquig® - J1551
    • 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.
  • Briumvi™ - J2329
  • Lemtrada® - J0202
  • Ocrevus™ - J2350
  • Tysabri® - J2323

Neutropenia

  • ​Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Fulphila™ - Q5108
  • Fylnetra® - Q5130
  • 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
  • Releuko™ - Q5125​
  • Rolvedon™ - J1449
  • Stimufend® - Q5127​
  • Udenyca™ - Q5111
  • ​Ziextenzo® - Q5120


Ophthalmic agents

  • Abicipar (pending FDA approval) - J3490, J3590, and C9399
  • Beovu® - J0179
  • Byooviz™ - Q5124
  • Cimerli™​ - Q5128
  • ​Eylea® - J0178 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • Eylea® HD – J3590 and C9399​
  • Lucentis® - J2778 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • Susvimo™- J2779
  • Tepezza® - J3241
  • Vabysmo® - J2777

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
  • Tezspire™ - J2356
  • 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
  • Amvuttra™ - J0225​
  • Cosela® - J1448
  • ​Crysvita® - J0584
  • Donislecel (pending FDA approval) – J3490, J3590, and C939​9
  • Enjaymo™ - J1302​
  • Evkeeza™ - ​J1305
  • Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
  • Gamifant® - J9210
  • Givlaari® - J0223
  • Ilaris® - J0638
  • Krystexxa® - J2507
  • Leqvio® - J1306​
  • Narsoplimab (pending FDA approval) - C9399 and J3590​
  • Onpattro® - J0222
  • Oxlumo™ - J0224
  • Reblozyl® - J0896
  • Remune (pending FDA approval) - J3490
  • Rethymic™ - J3590, and C9399
  • Soliris® - J1300 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)​
  • Spinraza™ - J2326
  • ​Tzield™ - J9381
  • Ultomiris™ - J1303
  • Uplizna™ – J1823
  • Vyepti™ - J3032​
  • Vyvgart™ - J9332
  • Vyvgart® Hytrulo – J3590 and C9399​
  • Xiaflex® – J0775
​

Revisions


October 1, 2023

 
The following revisions were incorporated into the October 1, 2023​ update.


Additions

Genetically and bio-engineered skin substitutes for wound care

A2022 Innovaburn or innovamatrix xl, per square centimeter
A2023 Innovamatrix pd, 1 mg
A2024 Resolve matrix, per square centimeter
A2025 Miro3d, per cubic centimeter

Electric, power, and motorized wheelchairs including custom accessories

K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds
E2300 Heat lamp, without stand (table model), includes bulb, or infrared element

Antineoplastic agents

Epkinly™ - C9155
Zynyz™ - J9345

Endocrine/metabolic agents

Achtar H.P.® - J0801 and J0802

Gene Replacement / Gene Editing Therapies

Roctavian™ - J3590 and C9399

Hemophilia/Coagulation factors

Altuviiio™ - J7214

Ophthalmic agents

Eylea® HD – J3590 and C9399

Miscellaneous therapeutic agents

Vyvgart® Hytrulo – J3590 and C9399


Deletions​​

Endocrine/metabolic agents

Acthar H.P.® - J0800

Gene Replacement / Gene Editing Therapies

Roctavian - J3490 and C9399


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