2016 Prior Authorization Requirements The Baptist Health Plan (BHP) list of medical services and specialty medications that require prior authorization (PA) has been updated. The effective date is January 1, 2016.
Please review carefully for any changes/updates. PA is the process of a member’s provider/physician requesting an authorization from BHP for any service listed on the PA list before the service is rendered. Only those services listed on the PA list require PA. Failure to request or obtain prior authorization for services listed on the PA list may result in additional member payments, reduced Plan payments or claim denial. We recommend verifying benefits and authorization requirements prior to providing services. BHP will not cover any service or supply, including treatment, procedures, hospitalizations, drugs, equipment, diagnostic, biological products or medical devices used in or directly related to the diagnosis, evaluation or treatment of a disease, injury, illness or other health condition which BHP determines to be Experimental/Investigational as defined by the member’s Certificate of Coverage. Services not requiring PA may have post service claim edits that will be reviewed for medical necessity and/or benefit coverage. All PAs are based on medical necessity and benefit limits and are not a guarantee of payment, payment level or member eligibility. PA applies to all BHP products/plans and must be initiated by the ordering provider. Self insured, employer sponsored programs for which BHP provides administrative services may customize their plans with different prior authorization requirements. If you have any questions or need additional information regarding the 2016 PA requirements, please contact BHP’s Customer Service Department at 800-787-2680 or 859-269-4475. The PA list is subject to change with notification.
RA 02/16.858
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received.
Category
Services Acute Care Hospital – Elective/Urgent/Emergent - Medical/Surgical
Comments Baptist Health Plan (BHP) is to be notified within 24 hours of an urgent/emergent/unscheduled admission or next business day
Long Term Acute Care (LTAC) Rehabilitation Facility Inpatient Admissions
Skilled Nursing Facility OB (Obstetrical) Related Medical Stays Newborn Stays Beyond Discharge of Mother NICU Admissions Scheduled C-Section or Induction of Labor Mental Health/Substance Abuse
PA for facility based care is through Optum Health Behavioral Solutions 877-369-2201
Articular surface repair using Autologous Chondrocyte Implantation (ACI) or Osteochondral Autograft Transplant Automatic Implantable CardioverterDefibrillator (AICD) Back/Spinal Surgery Balloon Sinuplasty Blepharoplasty Capsule Endoscopy Outpatient Surgery/ Procedures
Genetic Testing/Molecular Diagnostics
Not required for routine prenatal screening or routine newborn screenings; HLA testing for transplant
Joint Replacement Orthognathic Surgery
Inclusive of bone grafts, osteotomies and surgical management of TMJ syndrome
Radiofrequency Ablation, Cardiac Reduction Mammoplasty Spinal Cord Stimulator Insertion/Revision Varicose Vein Surgical Treatment & Sclerotherapy Ventricular Assist Devices
RA01/16.838
Page 2 of 9
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received. Category
Services
Comments
Ambulance Transfers
Non emergent air and ground; subject to retrospective review for medical necessity
Experimental/Investigational Services/Procedures Home Health/Home Infusion
PA through Care Continuum at 877-700-3482
Hyperbaric Oxygen Therapy In-Network Level of Benefits for Nonparticipating Providers for Non-Emergent Services
Other
Mental Health/Substance Abuse
PA through Optum Health Behavioral Solutions at 877-369-2201
Orthotics
Purchases $500 or greater
Power Morcellation for Uterine Fibroids Prosthetics
Purchases $2000 or greater
Real-Time Remote Heart Monitors Transplants – bone marrow and solid organ
Evaluation/Treatment/Procedure/Follow-Up Care
Brachytherapy CT Scan
PA is NOT required for CT guided biopsy
CTA Intensity-Modulated Radiotherapy (IMRT) Radiology/ Radiation Procedures
MRI MRA Nuclear Stress Test PET Scan Stereotactic Radiosurgery (SRS) & Stereotactic Body Radiotherapy (SBRT) 3-D Conformal Radiation Therapy
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Page 3 of 9
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received. Category
Services
Comments
Occupational Therapy Therapy Services
Physical Therapy
Prior Authorization after 12th visit if additional OT/PT/ST therapy services requested
Speech Therapy Chiropractic Services All Rentals Durable Medical Equipment
Purchases $500 or Greater
Including but not limited to: Bone Growth Stimulator; Communications Devices; CPAP; BiPAP; Wheelchairs; Pneumatic Pressure Devices; Continuous Insulin Infusion Pump; Electric Hospital Beds; Wound Vacuums
Dialysis Notification
Obstetric Care (Outpatient)
RA01/16.838
Baptist Health Community Care Maternity Program 844-246-2921
Page 4 of 9
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received.
Prior Authorization (PA) is required for the following drugs when delivered in all outpatient settings (i.e. physician office, clinic, outpatient hospital, or home setting). Must bill J-code on appropriate claim form. Home Health/Home Infusion is provided through the home health provider. Unless listed below, all selfadministered pharmacy products are covered under the Prescription Drug Benefit ONLY. Please contact BHP's Pharmacy Services Department at 877-205-6308 to request PA. Quantity Limit Drug Name J-code (if applicable) Brand Generic aripiprazole, extended Abilify Maintena J0401 release nanoparticle albumin-bound Abraxane J9264 paclitaxel Actemra IV tocilizumab J3262 800mg x 30 days Four 162mg syringes x 28 Actemra Sub-Q tocilizumab J3590; J3490; J9999 days Adcetris brentuximab vedotin J9042 Akynzeo* netupitant/palonosetron Q9978 Alimta pemetrexed J9305 Aloxi palonosetron J2469 5mL x 30 days J7180; J7181; J7182; J7185; J7186; J7187; Antihemophilic Factor Agents J7189; J7190; J7191; J7192; J7198; J7199 Aranesp darbepoetin alfa J0881; J0882 4 vials/syringes x 30 days Arcalyst rilonacept J2793 4 vials x 30 days Arranon nelarabine J9261 Arzerra ofatumumab J9302 Avastin bevacizumab J9035 Beleodaq* belinostat J9999 Benlysta belimumab J0490 Berinert C1 inhibitor, human J0597 Blincyto* blinatumomab J7799 Botox botulinum toxin J0585 Buprenex buprenorphine J0592 Ceprotin protein-C concentrate J2724
RA01/16.838
Page 5 of 9
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received.
Drug Name Brand Cerezyme Cimzia Cinryze Cyramza Dacogen Dysport Elelyso
Generic imiglucerase certolizumab pegol C1 inhibitor, human ramucirumab decitabine botulinum toxin taliflucerase
Jcode J1786 J0717 J0598 J9999; J3490; J3590 J0894 J0586 J3060
Eligard IM
leuprolide acetate
J9217
Ellence
epirubicin
J9178
Emend PO & IV
fosaprepitant
J1453; J8501
Entyvio*
vedolizumab
J3490; J3590
Epogen Erbitux Euflexxa Eylea Factor IX Concentrates Flolan Gazyva Gel-One Granix H.P. Acthar Gel Halaven Herceptin Hyalgan
epoetin alfa cetuximab sodium hyaluronate aflibercept
J0885; J0886 J9055 J7323 J0178 J7193; J7194; J7195; J7200; J7201 J1325 J9301 J7326 J1446 J0800 J9179 J9355 J7321
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epoprostenol sodium obinutuzumab sodium hyaluronate tbo-filgrastim corticotropin, ACTH eribulin mesylate trastuzumab sodium hyaluronate
Quantity Limit (if applicable)
2 x 30 days
7.5mg = 1 kit x 30 days; 22.5mg = 1 kit x 90 days; 30mg = 1 kit x 120 days; 45mg = 1 kit x 180 days 40mg, 115mg, 125mg & 150mg = 2 x 30 days; 80mg = 4 x 30 days; Therapy Pack = 6 x 30 days Initial = 4 x 4 months Maintenance = 7 x Calendar Year 12 x 30 days
Page 6 of 9
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received.
Drug Name Brand Ilaris
Immune globulin
Intron-A IV Invega Sustenna Ixempra Jetrea Jevtana Kadcyla Keytruda* Krystexxa Kyprolis Lemtrada Leukine Lucentis
Jcode
Generic canakinumab
J0638 J1459; J1460; 90281; J1556; J1557; J1559; J1560; J1561; J1562; IVIG J1566; J1568; J1569; J1572; J1559; J1599; 90284, 90283; interferon alfa J9214 aliperidone J2426 ixabepilone J9207 ocriplasmin J7316 cabazitaxel J9043 ado-trastuzumab emtansine J9354 pembrolizumab J3490; J3590; J9999 pegloticase J2507 carfilzomib J9047 alemtuzumab J3490; J3590 sargramostim J2820 ranibizumab J2778
Lupron Depot
leuprolide acetate
J9217; J9218; J1950
Macugen Makena
pegaptanib sodium hydroxyprogesterone methoxy polyethylene glycol-epoetin sodium hyaluronate plerixafor botulinum toxin
J2503 J1725
Mircera Monovisc Mozobil Myobloc
RA01/16.838
Quantity Limit (if applicable)
12 vials x 30 days
3.75mg, 7.5mg, & Pediatric Formulations = 1 kit x 30 days; 11.25 & 22.5mg = 1 kit x 90 days; 30mg = 1 kit x 120 days; 45mg = 1 kit x 180 days
J0887; J0888 J7327 J2562 J0587
Page 7 of 9
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received.
Drug Name
Jcode
Brand Neulasta Neupogen Nplate Omontys Opdivo* Orencia Orthovisc Pegasys PegIntron Perjeta Prialt Procrit Prolia
Generic pegfilgrastim filgrastim romiplostim peginesatide Nivolumab abatacept sodium hyaluronate peginterferon alfa-2a peginterferon alfa-2b pertuzumab ziconotide epoetin alfa denosumab
J2505 J1440; J1441; J1442 J2796 J0890 J3490; J3590; J9999 J0129 J7324 J3490 J3490 J9306 J2278 J0885; J0886 J0897
Provenge
sipuleucel-T
Q2043
Reclast Remicade Remodulin Risperdal Consta Rituxan Ruconest* Sandostatin IV/LAR Simponi ARIA Soliris Stelara Supartz Supprelin LA Sylatron Sylvant* Synagis Synvisc/SynviscOne
zoledronic acid infliximab treprostinil risperidone rituximab c1 esterase inhibitor octreotide golimumab eculizumab ustekinumab sodium hyaluronate histrelin acetate peginterferon alfa-2b siltuximab palivizumab
J3489 J1745 J3285 J2794 J9310 C9445 J2353; J2354 J1602 J1300 J3357 J7321 J9226 J3490; J3590 J3590 90378
sodium hyaluronate
J7325
RA01/16.838
Quantity Limit (if applicable)
14 syringes x 30 days
4 vials x 30 days 4 vials/syringes x 30 days 4 vials/pens x 30 days
12 vials x 30 days 1 treatment cycle per lifetime 1 dose every 6-8 weeks
300mL x 30 days
5 vials every 8 weeks 1 vial x 12 weeks
4 vials x 30 days 2 vials x 30 days
Page 8 of 9
Prior Authorization (PA) List for:
Fully Insured Plans
Effective and Current as of:
January 1, 2016
Phone:
877.449.2884 or 859.335.3737
It is recommended to verify benefits and authorization requirements prior to services being received.
Drug Name Brand Testosterone cypionate and enanthate injections and Testopel Pellet Tysabri Unituxin* Vantas Vectibix Veletri Vidaza Vimizim* Visudyne Vivitrol Vpriv Xeomin Xgeva
Jcode Generic
testosterone
J3121; S0189; J1071
J2323 J3490; J3590; J9999 J9226 J9303 J1325 J9025 J1322 J3396 J2315 J3385 J0588 J0897
Xolair Yervoy Zaltrap Zarxio*
natalizumab dinutuximab histrelin acetate panitumumab epoprostenol sodium azacitadine elosulfase alfa verteporfin naltrexone velaglucerase incobotulinumtoxinA denosumab collagenase clostridium histolyticum omalizumab ipilimumab ziv-aflibercept filgrastim
Zoladex
goserelin
J9202
Zometa Zyprexa Relprevv
zoledronic acid olanzapine
J3489 J2358
Xiaflex
RA01/16.838
Quantity Limit (if applicable)
Testopel: 6 pellets every 3 months* 1 vial x 30 days
J0775 J2357 J9228 J9400 J1440; J1441; J1442
14 syringes x 30 days 3.6mg = 1 kit x 30 days; 10.8mg = 1 kit x 90 days
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