Publication Date: 

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.

Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.


HCPCS or CPT® Codes Medicare Part B Drugs
C9399, J3490, J3590, J9999 Opdualag (nivolumab and relatlimab-rmbw)
C9096 Releuko (filgrastim-ayow)
A9699 Pluvicto (lutetium lu 177 vipivotide tetraxetan)
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NCBCBS-CR-005016-22-CPN4985 August 2022