Skip to main content
Shop Plans Learn more about our coverage options including health, Medicare, dental and vision options for you, your family or your employees. Get Started Individual & Family Medicare Employer Vision Dental International Travel Find Care FAQ Blog Members Stay on top of your health care with helpful member resources. Members Home Medicare Health Dental Vision Find Care Member Knowledge Center Member Forms Medicare Forms Library Make a Payment Federal Employees Student Blue Healthy Blue Providers Access tools, policies and the latest information to help you care for our members. Providers Home Network Participation Networks & Programs Claims, Appeals & Inquiries Prior Authorization Services & CPT codes Prescription Drug Search Policies, Guidelines & Codes Provider News Provider FAQ Contact Us Employers Learn about our coverage options for small and large employers, and access tools and resources for your group. Employers Home Shop Employer Plans Employer Portal Support Member Forms & Resources Find Care Blog Agents Access the tools you need: rate quotes, applications, forms, the latest industry news, marketing materials and more. Agents Home Agent Services Check Eligibility Find Care Member Forms & Resources Medicare Forms Library
Contact Us
Log In
I am ... Please select A member A provider An employer An agent
Log in to Agent Services
Log in to Employer Services Register for Employer Services I'm registered but need portal access
Username Forgot username? Continue to Log In Register for Blue Connect Need help? Learn how to log in.
Log in to Blue e Register for Blue e Log in to Dental Blue
Back
Part B Prior Authorization Criteria

Medicare Medical Policy

Last Review: 08/01/2024
Part B Prior Authorization Criteria for Approval

The requested Part B medication will be approved when BOTH of the following are met:

  1. ONE of the following:
    1. There is an applicable national coverage determination (NCD) or local coverage determination (LCD) from the Medicare Administrative Contractor (MAC) for the jurisdiction and the patient meets all of the requirements listed within the NCD or LCD
      OR
    2. There is NOT an applicable NCD or LCD and the requested medication is being used according to FDA labeling or in accordance with a CMS supported compendia (i.e., NCCN, Clinical Pharmacology, Lexicomp Lexi-Drugs, Merative Micromedex, & AHFS-DI) or published peer-reviewed literature
      AND
  2. ONE of the following:
    1. The requested medication is being evaluated for approval for the first time
      OR
    2. The request is for continuation of therapy and the patient has shown beneficial response to therapy

Length of Approval: See Table 1 below

Notes:

  • Length of approval may be shorter due to provider network participation status.
Table 1: Part B Prior Authorization
Bevacizumab (Oncology)
HCPCSMedicationLength of ApprovalNCD /LCD
Q5107Mvasi12 monthsN/A
Q5118Zirabev12 monthsN/A
Trastuzumab
HCPCSMedicationLength of ApprovalNCD /LCD
Q5117Kanjinti12 monthsN/A
Q5114Ogivri12 monthsN/A
Rituximab
HCPCSMedicationLength of ApprovalNCD /LCD
Q5119Ruxience12 monthsL35026
Q5115Truxima12 monthsL35026
Long-Acting Colony Stimulating Factors
HCPCSMedicationLength of ApprovalNCD /LCD
Q5111Udenyca / Udenyca Onbody12 monthsL37176
Q5120Ziextenzo12 monthsL37176
Short-Acting Colony Stimulating Factors
HCPCSMedicationLength of ApprovalNCD /LCD
J2820Leukine12 monthsL37176
Q5110Nivestym12 monthsL37176
Q5101Zarxio12 monthsL37176
Immune Globulins
HCPCSMedicationLength of ApprovalNCD /LCD
J1599Alyglo12 months

L34580

A56718

J1554Asceniv (IV)12 monthsL34580
J1556Bivigam (IV)12 monthsL34580
J1551Cutaquig (SC)12 monthsL33794
J1555Cuvitru (SC)12 monthsL33794
J1572Flebogamma (IV)12 monthsL34580
J1569Gammagard Liquid (IV or SC)12 months

L34580

L33794

J1566Gammagard S/D (IV12 monthsL34580
J1561Gammaked (IV or SC)12 months

L34580

L33794

J1557Gammaplex (IV)12 monthsL34580
J1561Gamunex-C (IV or SC)12 months

L34580

L33794

J1559Hizentra (SC)12 monthsL33794
J1575HyQvia (SC)12 monthsL33794
J1599Immune Globulin, intravenous, not otherwise specified12 monthsL34580
J1568Octagam (IV)12 monthsL34580
J1576Panzyga (IV)12 monthsL34580
J1459Privigen (IV)12 monthsL34580
J1558Xembify (SC12 monthsL33794
Infliximab
HCPCSMedicationLength of ApprovalNCD /LCD
Q5121Avsola12 monthsL35677
Q5103Inflectra12 monthsL35677
Miscellaneous
HCPCSMedicationLength of ApprovalNCD /LCD
J3490Empaveli12 monthsN/A

J3590

C9399

Enspryng12 monthsN/A
J2507Krystexxa12 monthsN/A
J0896Reblozyl12 monthsN/A
J9333Rystiggo12 monthsN/A

G2082

G2083

Spravato6 monthsN/A
J3241Tepezza6 monthsN/A
J1303Ultomiris12 monthsN/A
J1823Uplizna12 monthsN/A
J9332Vyvgart12 monthsN/A
J9334Vyvgart Hytrulo12 monthsN/A

*See separate medical drug policies for the following drugs: Amvuttra, Onpattro and Oxlumo.

Revision History

August 2024: Coding change: Added HCPCS codes J1599 for Alyglo effective 8/1/24;

Added HCPCS codes G2082/G2083 for Spravato effective 8/1/24;

Added HCPCS code J9333 for Rystiggo effective 8/1/24.

Added Udenyca Onbody to HCPCS code Q5111 effective 8/1/24.

Removed HCPCS code J1566 for Carimune NF effective 8/26/24.