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Download Summary of Changes 2017 Prior Authorization Requirements Below
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Summary of Changes 2017 Prior Authorization Requirements Below is a summary of changes to the Prior Authorization requirements for all Blue Cross® Blue Shield® Arizona Advantage members and providers. Specific DME codes have been added to the grid based on Medicare pricing. Please note that if an item is billed at an amount exceeding $1,000.00, prior authorization is required regardless of code. 2017 code changes are as follows: Additions: Part B Drug Name Iluvien Ozurdex Mircera Gel-Syn Genvisc 850 Hymovis Monovisc Cinqair Nucala Stelara 2017 (New Code) 36473 62320 62321 62322 December 5, 2016 Effective 1/1/2017 fluocinolone acetonide intravitreal implant dexamethasone intravitreal implant methoxy polyethylene glycolepoetin beta hyaluronan or derivative hyaluronan or derivative hyaluronan or derivative hyaluronan or derivative reslizumab mepolizumab IV infusion Code J7313 J7312 J0887 & J0888 J7328 Q9980 J3490, C9471 J7327 J3590, J3490 J3590 J3590 Description Endovenous ablation therapy of incompetent vein, extremity, Inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for Page 1 of 2 62323 62324 62325 62326 62327 localization when performed, epidural or subarachnoid; lumbar or sacral (caudal); without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic; without imaging guidance Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal); without imaging guidance Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) Deletions: Part B Drug Name Flolan Avastin for non-cancer use Simulect Vibativ 2017 (Deleted Code) 22851 62318 62319 December 5, 2016 Effective 1/1/2017 injection, epoprostenol, 0.5mg bevacizumab basiliximab injection, telavancin 10 mg Code J1325 J7999 or J9035 J0480 J3095 Description Application Of Intervertebral Biomechanical Device(S) (Eg, Synthetic Cage(S), Me Njxs Infus/Bolus Dx/Sbst Edrl/Subarach Crv/Thrc Njx Infus/Bolus Dx/Sbst Edrl/Subarach Lum/Sacral Page 2 of 2 Please contact your provider representative if you have any questions about this information. December 5, 2016 Effective 1/1/2017 Page 3 of 2
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