Changes To Specialty Drugs Preauthorization List: Always Check Preauthorization Requirements

Jun. 11, 2019

Blue Cross and Blue Shield of Montana (BCBSMT) has updated its Specialty Drugs Preauthorization List for Infusion Site of Care. Two codes have changed. The changes reflect these drugs’ new replacement Healthcare Common Procedure Coding System (HCPCS) codes assigned by The Centers for Medicare & Medicaid Services (CMS):

As a reminder, the following behavioral health services typically need preauthorization:

  • Fasenra – changed from C9466 to J0517
  • Radicava – changed from C9493 to J1301

The Specialty Drugs Preauthorization List for Infusion Site of Care can be found on the BCBSMT provider website on the Predetermination and Preauthorization page under Claims and Eligibility.

For these select drugs you may need to submit a benefit preauthorization request to BCBSMT prior to administration of the drug and selection of Infusion Site of Care.

We encourage you to check eligibility and benefits via an electronic 270 transaction through the Availity® Provider Portal or your preferred vendor portal. It’s also important to check eligibility and benefits for each patient at every visit to confirm coverage details. This step also helps you identify benefit preauthorization/prenotification requirements.

You may also call the number on the member’s ID card for assistance.

Also, stay current with BCBSMT Medical Policy, under “Specialty Medication Administration Site of Care” RX 501.096.

For more information refer to the Predetermination and Preauthorization web page and Specialty Pharmacy Program web page on our provider website.

Checking eligibility and benefits and/or obtaining benefit preauthorization/prenotification or predetermination of benefits is not a guarantee that benefits will be paid. Payment is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations and exclusions set forth in your patient’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any benefit determination, the final decision regarding any treatment or service is between you and your patient.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third-party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.