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​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Services that require precertification for AmeriHealth New Jersey Members (Effective 10/01/2025)​​​

​Services that Require Precertification for AmeriHealth New Jersey Members


As of October 1, 2025, this list applies to all AmeriHealth New Jersey HMO, POS, EPO, 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.

Precertification is not a determination of eligibility or a guarantee of payment. Coverage and payment are contingent upon, among other things, the patient being eligible, i.e., actively enrolled in the health benefits plan when the precertification is issued and when approved services are provided. Coverage and payment are also subject to limitations, exclusions, and other specific terms of the health benefits plan that apply to the coverage request. In addition to the precertification requirements listed above, you should contact AmeriHealth New Jersey and provide prenotification for certain categories of treatment so you will know prior to receiving treatment whether it is a covered service. The categories of treatment (in any setting) that require prenotification include: 

  • Any surgical procedure that may be considered potentially cosmetic;
  • Any procedure, treatment, drug, or device that represents “new or emerging technology," including infusion therapy drugs newly approved by the FDA;
  • Services that might be considered experimental/investigational.


Note: If a non-emergent service is unavailable from a provider within the network, precertification for a plan exception for out-of-network coverage may be requested for those members who do not have an out-of-network benefit. Please refer to the AmeriHealth New Jersey Provider Manual for Participating Professional Providers (Provider Manual) for additional information on out-of-network requests.

The list of services requiring precertification is subject to change. For questions about precertification, please call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241).

You can also go to amerihealthnj.com/html/providers/policies.html to learn more about precertification requirements for all products.


All Home-Care Services (including I​nfusion 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. Precertification review only applies to members for whom the Program is applicable.  For additional information, refer to the current version of Medical Policy 11.02.27, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound.

Arterial Ultrasound

​​9​3978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931

Diagnostic Coronary Angiography

​93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7552, C7553, C7557, C7562

Percutaneous Coronary Intervention

​​​​92920, 92924, 92928, 92933, 92937, 92943, C9600, C9602, C9604, C9607​


​

Procedures


  • Cochlear Implant Surgery and Associated Supplies/Bone-Anchored (Osseointegrated) Hearing Aids, Implantable Bone Conduction Hearing Aids

    69714, 69715, 69717, 69718, 69930, L8614,​ L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693 
       
  • Obesity Surgery

    43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999 
    ​

Musculoskeletal Procedures


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 00.01.66, Musculoskeletal Services.


​Allograft

​29032, 29033, 29034

Bone Grafts

​20930, 20931, 20932, 20933, 20934, 20936, 20937, 20938

Bone Growth Stimulator

​E0748

Cervical Spine Surgery - Anterior Decompression with Fusion

​22551, 22552, 22554, 22830, 22585, 63081, 63082

​Cervical Spine Surgery - Anterior Decompression without Fusion

​63075, 63076
​
Cervical Spine Surgery - Posterior Decompression with Fusion

​22600, 22614, 22632, 22634, 22830, 22864

Cervical Spine Surgery - Posterior Decompression without Fusion

​63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051, 63052, 63053

Cervical Total Disc Replacement (Arthroplasty)

​0095T, 0098T, 22856, 22858, 22861, 22864

Hip Arthroscopy

​27120, 27122, 29860, 29861, 29862, 29863, 29914, 29915, 29916

Hip Replacement

​27125, 27130, 27132, 27134, 27137, 27138, S2118

Knee Arthroscopy

​29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Knee Open

​27331, 27332, 27333, 27334, 27335, 27345, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429

Knee Replacement

​27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, J7330, S2112

Lumbar Decompression (Laminotomy/Laminectomy/Discectomy/Formanitomy)

​63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, S2350, S2351

Lumbar Disc Replacement (Arthroplasty)

​0164T, 0165T, 22857, 22860, 22862, 22865

Lumbar Fusion

​22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22830

​​Sacroiliac Joint Fusion

​27279, 27280, C1737

Shoulder - Arthroscopic and Open Procedures

​23105, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828

Shoulder Replacement

​23470, 23472, 23473, 23474

Spinal Deformity (Scoliosis/Kyphosis)

​22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22610, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308

Spinal Instrumentation

​22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859

Vertebroplasty, Kyphoplasty

​​22510, 22511, 22512, 22513, 22514, 22515, C7504, C7505, C7507, C7508​



Interventional Pain Management Services


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. 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

  • Cervical or Thoracic Epidural Steroid Injection
​62320, 62321, 64479, 64480

  • Lumbar or Sacral Epidural Steroid Injection
​62322, 62323, 64483, 64484

Paravertebral Facet Injection/Nerve Block/Neurolysis

  • Cervical or Thoracic Facet Injection
​64490, 64491, 64492

  • Cervical Radiofrequency Ablation
​64633, 64634

  • Lumbar or Sacral Facet Injection
​64493, 64494, 64495

  • Lumbar Radiofrequency Ablation
​64635, 64636

​​​Sacroiliac Joint injections

​​27096, G0260

Spinal Cord and Nerve Root Stimulators

  • Implantation of Spinal Cord Stimulators​
​63650, 63655, 63663, 63664, 63685, 63688

​​Regional Sympathetic Nerve Blocks

​​64510, 64520


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, 19300, 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

    17999
     
  • 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 Affirming Interventions 

    11920, 11921, 11922, 11960, 15877, 17380, 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 Dare

    A2001, A2002, A2004, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021, A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039, 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, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4227, Q4228, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, 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, Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4314, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4344, Q4345, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4368, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4392, Q4393, Q4394, Q4395, Q4396, Q4396, Q4397

  • Gynecomastia
19300​

  • Hair Transplant

    15775, 15776

  • Injectable Dermal Fillers

​​​​Effective 07/01/2023, procedure codes that represent Injectable Dermal Fillers (11950, 11951, 11952, 11954, Q2026, and Q2028) no longer require precertification for Independence Commercial Lines of Business.​
​
  • 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, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, S2202​​


Day Rehabilitation Programs 


​0931, 0932​


Elective (Nonemergency) Ground, Air, and Sea Ambulance Transportation


A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961


Outpatient Private-Duty Nursing


S9123, S9124

​

Outpatient Radiation Therapy


Precertification is performed by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 09.00.56, Radiation Therapy Services.​


​​​Brachytherapy

0394T, 0395T, 77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, 77789, G0458

​Cardiac Focal Ablation

0747T

Hyperthermia Treatment

77600, 77605, 77610, 77615, 77620

Image-Guided Radiation (IGRT)

77014, 77387, G6001, G6002, G6017


Intensity Modulated Radiation Therapy (IMRT)

77385, 77386, G6015, G6016


Intraoperative Radiation Therapy (IORT)

77424, 77425


Neutron Beam Radiation Therapy

77423


Proton Beam Radiation Therapy

77520, 77522, 77523, 77525


Radiation Treatment Delivery

77401, 77402, 77407, 77412, A9609, G0563, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014


Stereotactic Radiation Therapy

77371, 77372, 77373, G0339, G0340


Therapeutic Radiopharmaceuticals

77750, 79005, 79101, 79403, A9513, A9543, A9590, A9606, A9607, A9699, C2616, S2095


Radiology


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA09.002, High-Technology Radiology Services.


Computed Tomography (CT)

  • Abdomen
74150, 74160, 74170

  • Abdomen and Pelvis
74176, 74177, 74178

  • Cervical Spine
72125, 72126, 72127

  • Chest
71250, 71260, 71270

  • Head
0042T, 70450, 70460, 70470

  • Lower Extremity
73700, 73701, 73702

  • Lumbar Spine
72131, 72132, 72133

  • Lung
71271

  • Neck
70490, 70491, 70492

  • Orbit
70480, 70481, 70482

  • Pelvis
72192, 72193, 72194

  • Sinus
70486, 70487, 70488

  • Thoracic Spine
72128, 72129, 72130

  • Upper Extremity
73700, 73701, 73702

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET)/Computed Tomography (CT)

  • Computed Tomography (CT) Heart for Calcium Scoring
75771

  • Coronary Computed Tomography (CT) and Computed Tomography Angiography (CTA)
0503T, 75572, 75573, 75574, 75580

  • Tumor Imaging
78811, 78812, 78813, 78814, 78815, 78816

Computed Tomography Angiography (CTA)

  • Abdomen
74175

  • Abdomen and Pelvis
74174

  • Abdominal Arteries
75635

  • Chest
71275

  • Head
70496

  • Lower Extremity
73706

  • Lung
71271

  • Neck
70498

  • Pelvis
72191

  • Upper Extremity
73206

CT Heart for Calcium Scoring

75571

Diagnostic Computed Tomography (CT) Colonoscopy

74261, 74262

Fluorine-18 fluorodeoxyglucose (f-18 FDG)

S8085

Follow Up Study Computed Tomography (CT)

76380

Functional Magnetic Resonance Imaging (MRI) Brain

70554, 70555

Low-Field MRI

​S8042

Magnetic Resonance Angiography (MRA)

  • Abdomen
74185, C8900, C8901, C8902

  • Chest
71555, C8909, C8910, C8911

  • Head
615, 70544, 70545, 70546

  • Lower Extremity
73725, C8912, C8913, C8914

  • Neck
615, 70547, 70548, 70549

  • Pelvis
72198, C8918, C8919, C8920

  • Spinal Canal
72159, C8931, C8932, C8933

  • Upper Extremity
73225, C8934, C8935, C8936

​Magnetic Resonance Elastograhpy

​76391

​Magnetic Resonance Imaging (MRI)

  • Abdomen
74181, 74182, 74183, S8037

  • Bone Marrow
77084

  • Brain
70551, 70552, 70553

  • Breast
77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908

  • Cardiac
75557, 75559, 75561, 75563, 75565, C9762, C9763

  • Cervical Spine
72141, 72142, 72156

  • Chest
71550, 71551, 71552

  • Fetal
74712, 74713

  • Lower Extremity
73718, 73719, 73720, 73721, 73722, 73723

  • Low Field MRI
S8042

  • Lumbar Spine
72148, 72149, 72158

  • Orbit
70540, 70542, 70543

  • Pelvis
72195, 72196, 72197

  • Temporomandibular Joint (TMJ)
70336

  • Thoracic Spine
72146, 72147, 72157

  • Upper Extremity (Any Joint)
73221, 73222, 73223

  • Upper Extremity (Non-Joint)
73218, 73219, 73220

​Magnetic Resonance Spectroscopy (MRS)

76390

Magnetic Resonance Technology (MRT)

616

Magnetoencephalography (MEG)

  • ​Head

95965, 95966*


Nuclear Cardiology​​​

  • Cardiac Blood Pool Imaging
78472, 78473, 78481, 78483, 78494, 78496

  • Infarct Imaging
0742T, 78451, 78452, 78453, 78454, 78466, 78468, 78469

Positron Emission Tomography (PET)

  • Brain Imaging
78608, 78609

  • Myocardial Imaging
78429, 78430, 78431 78432, 78433, 78434, 78459, 78491, 78492

  • Other Imaging Services
404

Quantitative Computed Tomography (QCT) Bone Densitometry

77078

Resting Transthoracic Echocardiography (TTE)

93303, 93304, 93306, 93307, 93308

  • Echocardiography Add-On Codes
93319, 93320, 93321, 93325, 93352

Screening Computed Tomography (CT) Colonoscopy

74263

Stress Echocardiography

93350, 93351

  • Echocardiography Add-On Codes
93320, 93321, 93325, 93352

Transesophageal Echocardiography (TEE)

93312, 93313, 93314, 93315, 93316, 93317

  • Echocardiography Add-On Codes
93319, 93320, 93321, 93325

3-D Rendering

  • ​​Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Grouping
76376, 76377​

* Precertification for these codes will become effective November 15, 2025.

Prosthetics/Orthoses


Follow New Jersey orthotics and prosthetics mandate, as applicable. Items addressed by the mandate do not require precertification.


Selected Durable Medical Equipment (DME)


  • Bone Growth Stimulators

    Low-Intensity Ultrasound Noninvasive Bone Growth Stimulation
    E0760

    Other Than Spinal Noninvasive Electrical Bone Growth Stimulation
    E0747

    Spinal Noninvasive Electrical Bone Growth Stimulation
    E0748

  • 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 Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 07.03.05, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies.
A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0470, E0471, E0561, E0562, E0601, E1399

  • 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, 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, 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. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 07.03.05, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies.

95782, 95783, 95805, 95807, 95808, 95810, 95811

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) 
​0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869

  • Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)

Autism Spectrum Disorders

​

  • Applied behavioral analysis

​​0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158


Genetic and Genomic Tests Requiring Precertification


Precertification is performed by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 06.02.52, eviCore Lab Management Program.

The following list is a guide to the types of genetic and genomic tests that require precertification. 


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

The following are the specific CPT and HCPCS codes for genetic and genomic tests that require pre-service reviews by CareCore National, LLC d/b/a eviCore healthcare (eviCore).​


  • Molecular Pathology
0001U, 0005U, 0016U, 0017U, 0018U, 0019U, 0022U, 0026U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0045U, 0047U, 0048U, 0050U, 0055U, 0060U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0179U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0297U, 0298U, 0299U, 0300U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0355U, 0356U, 0362U, 0363U, 0364U, 0368U, 0379U, 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0418U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0488U, 0489U, 0493U, 0494U, 0495U, 0496U, 0497U, 0498U, 0499U, 0501U, 0506U, 0507U, 0508U, 0509U, 0510U, 0516U, 0532U, 0533U, 0534U, 0536U, 0537U, 0538U, 0539U, 0540U, 0543U, 0544U, 0549U, 81162, 81163, 81164, 81165, 81166, 81167, 81173, 81174, 81185, 81186, 81189, 81190, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81221, 81222, 81223, 81225, 81226 81227, 81228, 81229, 81230, 81231, 81232, 81238, 81248, 81249, 81252, 81253, 81257, 81258, 81259, 81269, 81277, 81283, 81286, 81289, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81308, 81313, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 81326, 81327, 81328, 81335, 81336, 81337, 81346, 81349, 81350, 81351, 81353, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81493, 81518, 81522, 81523, 81542, 81552

  • Molecular HCPCS Codes
G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3850, S3852, S3854, S3861, S3865, S3866, S3870

  • Multianalyte Assays with Algorithmic Analyses (MAAA)
0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0016M, 0017M, 0020M, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0228U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0329U, 0331U, 0444U, 0523U, 0529U, 0530U, 0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U, 0572U, 81195, 81504, 81519, 81520, 81521, 81525, 81529, 81540, 81541, 81546, 81551, 81554, 81558, 81595

  • ​Unlisted Molecular Codes (When Reported With Genetic/Genomic Testing)

81479, 81599, 84999


Specialty Drugs Requiring Precertification


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

Amyotrophic Lateral Sclerosis Agents

  • NurOwn® - J3490, J3590, and C9399​
    • ​

Antineoplastic Agents

  • Abraxane® - J9264
  • ​Adstiladrin® - J9029​
  • Adcetris® - J9042
  • Anktiva® - J9028
  • Alymsys® - Q5126 (Note: Ophthalmologic use of Alymsys does not require precertification.)​
  • ​Avastin® - C9257, J9035, and Q5129 (Note: Ophthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Avzivi® - J3490, J3590, and C9399​
  • Azedra®​* - A9590
  • Bizengri® - J9382​
  • Blincyto™ - J9039
  • Columvi™ - J9286​
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro™ – J9144
  • Datroway® - J9011
  • Elahere™ - J9063
  • Elrexfio™ - J1323
  • ​Emrelist™ - C9306 and J3590​
  • Enhertu® - J9358
  • Epkinly™ - J9321​
  • Erbitux® - J9055
  • Herceptin® - J9355 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Herceptin® Hylecta - J9356
  • Herzuma®​ - Q5113
  • Imjudo® - J9347​
  • Instiladrin (pending FDA approval) - J3490 and C9399
  • Kadcyla® - J9354
  • Kimmtrak® - J9274
  • Kyprolis® - J9047
  • Lunsumio™ - J9350
  • Margenza™ - J9353
  • Monjuvi® - J9349​
  • Ogivri™ - Q5114
  • Ontruzant®​- Q5112
  • Opdualag™ - J9298
  • Padcev™- J9177
  • ​Patritumab deruxtecan - J3490, J3590, and C9399​
  • Pemfexy™ - J9304
  • 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
  • Rybrevant™ – J9061​​​
  • ​Rylaze™ - J9021​
  • Rytelo™ - J0870​
  • Sarclisa® - J9227
  • Taclantis​ (pending FDA approval) - J3490 and C9399
  • Talvey™ - J3055​
  • Tecvayli™ - J9380 
  • Tivdak™ - J9273
  • Trodelvy®- J9317
  • ​Vyloy® - J1326
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca™ – J9223
  • Zevalin®* - A9543
  • Ziihera® - J9276
  • ​Zynlonta™ J9359

*​​​​ Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).  Precertification review only applies to members for whom the Program is applicable.​


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
  • Camrelizumab (pending FDA approval) - J3490, J3590, and C9399
  • Imfinzi™ - J9173
  • Jemperli™ - J9272
  • Keytruda™ - J9271
  • Libtayo® - J9119
  • Opdivo® - J9299
  • Opdivo Qvantig™ - J9289​
  • Tecentriq™ - J9022
  • Tecentriq Hybreza™ - J9024​
  • Tevimbra® - J9329
  • Unloxcyt™ - J9275​
  • ​Zynyz™ - J9345​
    • ​​

Bone-Modifying Agents


  • Bomyntra® and Conexxance® - Q5158
  • Evenity™ - J3111
  • Jubbonti® - Q5136​
  • Ospomyv™ and Xbryk - Q5159
  • Prolia® - J0897
  • Stoboclo® and Osenvelt® - Q5157
  • Wyost® - Q5136​
  • Xgeva® - J0897

Botulinum Toxin Agents


  • Botox® - J0585

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
  • ​Aucatzyl® - Q2058​
  • Breyanzi® - Q2054​
  • Carvykti™ - Q2056
  • Kymriah™ - Q2042
  • Tecartus™ - Q2053
  • Yescarta™ - Q2041
  • Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 38228

Endocrine/Metabolic Agents

  • Achtar H.P.® - J0801 and J0802
  • Lanreotide – J1932​​
  • Lutathera®* - A9513 and A9699
  • Lutathera®* - A9513 and A9699​
  • Sandostatin® LAR - J2353
  • Somatuline® depot - J1930​
  • Xenpozyme™ - J0218

​​* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).​ Precertification review only applies to members for whom the Program is applicable.​

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
  • Adzynma - J7171​
  • Brineura™ - J0567
  • Cerezyme® - J1786
  • Cinaxadamtase Alfa (pending FDA approval) – J3490, J3590, and C9399
  • Cipaglucosidase Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Elaprase® - J1743
  • Elelyso® - J3060
  • Elfabrio® - J2508​
  • Fabrazyme® - J0180
  • Kanuma® - J2840
  • Lamzede® - J0217​
  • Lumizyme® - J0221
  • Mepsevii™ - J3397
  • Naglazyme® - J1458
  • Nexviazyme™ - J0219
  • Pombiliti™ - J1203
  • 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.

​

  • Casgevy™ - J3392
  • Eladocagene exuparvovec - J3490, J3590, and C9399​
  • Elevidys® - J1413
  • Hemgenix® - J1411​
  • Lenmeldy™ - J3391​
  • Luxturna™ - J3398
  • ​Lyfgenia™ - J3394​
  • Marnetegragene aututemcel - J3490, J3590, and C9399
  • ​Roctavian® - J1412​
  • Skysona® - J3590 and C9399​
  • Vvjuvek™ - J3401​
  • Zevaskyn™ - C9399 and J3590​
  • Zolgensma® - J3399
  • Zynteglo® - J3393

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
  • ​Alhemo® - J7173​
  • 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
  • Helixate FS® - J7192
  • Hemlibra® - J7170
  • Hemofil-M® - J7190
  • Humate-P® - J7187
  • Hympavzi™ - J7172​
  • 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
  • Qfitlia™ - J7174​
  • 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®- J3262 (See note below.)
  • Avtozma® - Q5156​
  • Benlysta® IV - J0490
  • Cosentyx® IV - J3427​
  • Entyvio™ - J3380 (See note below.)
  • Ilumya™ - J3245
  • Imuldosa® - Q5098
  • Omvoh™ - J2267​
  • Orencia® IV- J0129
  • Otulfi® - Q9999​
  • Pyzchiva® - Q9996 and Q9997
  • ​Saphnelo™ - J0491
  • Selarsdi™ - Q9998
  • Simponi® Aria - J1602
  • Skyrizi® IV - J2327
  • Spevigo® - J1747
  • Stelara®​- J3357 and J3358    
  • Steqeyma® - Q5099​
  • Tofidence™ - Q5133​
  • ​​Tremfya® IV - J1628​
  • Tyenne® - Q5135​
  • ​Wezlana – Q5137, Q5138​
  • Yesintek™ - Q5100​


HCPCS codes J3362 and J3380 will only require precertification when not reported with the JB modifier.

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)
    • ​Alyglo™ - J1552
    • Asceniv® - J1554
    • Bivigam® - J1556
    • Flebogamma® - J1572
    • Flebogamma®-Dif - J1572
    • Gammagard®Liquid - 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
  • Ocrevus Zunovo® - J2351​
  • Tyruko® - Q5134
  • Tysabri® - J2323

Myasthenia Gravis 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.

  • Imaavy™ - C9305 and J3590​
  • Rystiggo® - J9333
  • Vyvgart™ - J9332
  • Vyygart® Hytrulo - J9334​

Neutropenia

​

  • Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Fulphila™ - Q5108
  • Fylnetra® - Q5130​
  • Granix® - J1447​
  • Lapelga (pending FDA approval) - J3490, J3590, and C9399
  • Neupogen® - J1442​
  • Nypozi® - Q5148
  • Releuko™ - Q5125
  • Rolvedon™ - J1449​
  • Ryzneuta® - J9361​
  • Stimufend® - Q5127
  • Udenyca™ - Q5111
  • Ziextenzo® - Q5120


Ophthalmic Agents

​

  • Ahzantive® - Q5150​
  • Beovu® - J0179
  • Byooviz™ - Q5124
  • Cimerli™ - Q5128​
  • Encelto™ - J3403
  • Enzeevu™ - Q5149​
  • Eylea® - J1078 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​​
  • ​Eylea® HD – J1077 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Lucentis® - J2778 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Opuviz - Q5153
  • Pavblu™ - Q5147​
  • ​​Susvimo™- J2779
  • Tepezza® - J3241
  • Vabysmo® - J2777
  • ​Yesafili™ - Q5155


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
  • Tyvaso® - J7686
  • ​Uptravi® IV - J3490 and C9399​
  • Veletri® - J1325
  • Ventavis® - Q4074

Respiratory Agents


  • Cinqair® - J2786
  • Omlyclo® - Q5154​
  • 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


Tumor Infiltrating Lymphocyte (TIL) 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.​

  • Amtagvi™ – J3590, and C9399​
  • Imdelltra™- J9026
  • Lynozyfic™ - C9399 and J3590​
  • ​Tecelra® - Q2057​


Miscellaneous Therapeutic Agents


  • Adakveo® - J0791
  • Ampligen® (pending FDA approval) - J3490
  • Amvuttra™ - J0225​
  • Bkemv™ - Q5152​
  • Cosela® - J1448
  • Crysvita®- J0584
  • Enjaymo™ - J1302
  • Epysqli® - Q5151​
  • Evkeeza™ - J1305
  • Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
  • Gamifant® - J9210
  • Givlaari®- J0223
  • Ilaris® - J0638
  • Injectafar® - J1439​
  • Krystexxa®​ - J2507
  • Lantidra® - J3490, J3590, and C9399​
  • Leqvio® - J1306​
  • Monoferric® - J1437​
  • Narsoplimab (pending FDA approval) - C9399 and J3590​
  • Niktimvo™ - J9038​
  • Onpattro® - J0222
  • Oxlumo™ - J0224​​
  • Panhemitin® - J1640​
  • ​PiaSky® - J1307​
  • Reblozyl® - J0896
  • Remune - J3490
  • Rethymic™ - J3590, and C9399
  • ​Soliris® - J1299​
  • Spinraza™ - J2326
  • Tzield- J9381​
  • Ultomiris™ - J1303
  • Uplizna™ – J1823
  • Veopoz™ - J9376​
  • Vyepti™ - J3032
  • Xiaflex® – J0775​

Revisions 


October 1, 2025

​

The following revisions were incorporated into the October​ 1, 2025​ update.​

Additions​

Genetically and Bio-Engineered Skin Substitutes for Wound Care

A2036 Cohealyx collagen dermal matrix, per square centimeter
A2037 G4derm plus, per milliliter
A2038 Marigen pacto, per square centimeter
A2039 Innovamatrix fd, per square centimeter
Q4383 Axolotl graft ultra, per square centimeter
Q4384 Axolotl dualgraft ultra, per square centimeter
Q4385 Apollo ft, per square centimeter
Q4386 Acesso trifaca, per square centimeter
Q4387 Neothelium ft, per square centimeter
Q4388 Neothelium ft, per square centimeter
Q4389 Neothelium 4l+, per square centimeter
Q4390 Ascendion, per square centimeter
Q4392 Grafix duo, per square centimeter
Q4393 Surgraft ac, per square centimeter
Q4394 Surgraft aca, per square centimeter
Q4395 Acelagraft, per square centimeter
Q4396 Natalin, per square centimeter
Q4397 Summit aaa, per square centimeter

Radiology

Magnetoencephalography (MEG)

Head
95965, 95966

Antineoplastic Agents

Datroway® - J9011
Emrelist™ - C9306 and J3590

Bone-Modifying Agents

Bomyntra® and Conexxance® - Q5158
Ospomyv™ and Xbryk - Q5159
Stoboclo® and Osenvelt® - Q5157

Gene Replacement / Gene Editing Therapies

Zevaskyn™ - C9399 and J3590

Hemophilia/Coagulation Factors

Alhemo® - J7173
Qfitlia™ - J7174

Immunological Agents

Avtozma® - Q5156

Myasthenia Gravis Agents

Imaavy™ - C9305 and J3590

Ophthalmic Agents

Encelto™- J3403
Yesafili™ - Q5155

Respiratory Agents
 
Omlyclo® - Q5154

Tumor Infiltrating Lymphocyte (TIL) Therapy

Lynozyfic™ - C9399 and J3590​

​_________________________________________________________________

Deletions

Antineoplastic Agents

Datroway® - C9174

Gene Replacement / Gene Editing Therapies

Prademagene zamikeracel - J3490, J3590, and C9399

Ophthalmic Agents

Yesafili™ - J3490, J3590, and C9399

Tumor Infiltrating Lymphocyte (TIL) Therapy

Linvoseltamab - J3490, J3590, and C9399


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