Specialty Pharmacy Precertification List Expansion (Healthy Blue + Medicare HMO D-SNP)
Please note, this communication applies to Healthy Blue + Medicare℠ (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.
Effective for dates of service on and after April 1, 2023, 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 | Rolvedon (eflapegrastim-xnst) |
| C9399, J3490, J3590 | Stimufend (pegfilgrastim-fpgk) |
For more information, visit Healthy Blue + Medicare.
NCBCBS-CR-010708-22-CPN9557 December 2022
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2024 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.