Provider Authorization Update - Part B Drugs

Date: 01/30/19

PA Health & Wellness requires prior authorization as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by PA Health & Wellness.

PA Health & Wellness is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent, objective medical criteria.

It is the ordering provider’s responsibility to determine which specific codes require prior authorization. Effective May 1, 2019, prior authorization requirements will be added to the Part B Drugs listed below. Please refer to the information below for guidance regarding how to obtain prior authorizations from PA Health & Wellness.

FREQUENTLY ASKED QUESTIONS:

How do I determine if a specific treatment requires prior authorization?

You may determine which specific codes require prior authorization by visiting our website at PAHealthWellness.com and clicking on the Pre-Auth Check tab. The Pre-Auth Check tab will take you to our PreScreen Tool. Just enter the CPT code and the PreScreen Tool will advise you whether the service requires prior authorization.

How do I request a prior authorization for these services?

You may submit the prior authorization request utilizing our Secure Web Portal at PAHealthWellness.com. If your request is approved, you will receive verification through the Secure Web Portal. If you are not currently registered on our Secure Web Portal, you may register through a quick and simple process.
You may submit the prior authorization request by faxing an authorization to 1-844-259-4568. The fax authorization form can be found on our website at PAHealthWellness.com.
You may call our Medical Management department at HMO: 1-855-766-1456 HMO SNP: 1-866-330-6398 (TTY: 711).

What information will I be required to submit in connection with the prior authorization request?

Pertinent clinical information related to the request
CPT code
Diagnosis Code
Rendering facility’s name, Tax ID number, and NPI number

If you have any questions regarding this information, you may contact Provider Services at HMO: 1-855-766-1456 HMO SNP: 1-866-330-6398 (TTY: 711) or contact your dedicated Provider Relations Specialist.

Please verify eligibility and benefits prior to rendering services. Prior Authorization will be required for these Part B Drugs effective May 1, 2019.

Medicare Part B Drugs
CPT Code	Code Description
C9028	INJ INOTUZUMAB OZOGAMICIN
C9031	LUTETIUM LU 177 DOTATATE THER 1 MCI
C9465	INJECTION, DUROLANE
C9466	INJECTION, BENRALIZUMAB
C9467	INJ RITUXIMAB HYALURONIDASE
C9483	INJECTION ATEZOLIZUMAB
C9492	INJECTION, DURVALUMAB, 10 MG
J0604	CINACALCET ORAL 1 MG
J0606	INJECTION ETELCALCETIDE 0.1 MG
J0641	LEVOLEUCOVORIN INJECTION
J0775	COLLAGENASE, CLOST HIST INJ
J0897	DENOSUMAB INJECTION
J1190	INJ DEXRAZOXANE HYDROCHLORIDE PER 250 MG
J1428	INJECTION ETEPLIRSEN 10 MG
J1439	INJ FERRIC CARBOXYMALTOS 1MG
J1447	INJECTION TBO-FILGRASTIM 1 MICROG
J1555	INJECTION IMMUNE GLOBULIN 100 MG
J1627	INJ GRANISETRON EXT-RLSE 0.1 MG
J1640	INJECTION, HEMIN, 1 MG
J1743	IDURSULFASE INJECTION
J1930	LANREOTIDE INJECTION
J1950	INJ LEUPROLIDE ACETATE PER 3.75 MG
J2326	INJECTION NUSINERSEN 0.1 MG
J2350	INJ NIACINAMIDE NIACIN TO 100 MG
J2353	INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG
J2562	PLERIXAFOR INJECTION
J2783	INJECTION, RASBURICASE, 0.5 MG
J2840	INJ SEBELIPASE ALFA 1 MG
J3095	TELEVANCIN INJECTION
J3240	INJ THYROTROPIN .9 MG PROV 1.1 VIAL
J3315	INJ TRIPTORELIN PAMOATE 3.75 MG
J3380	INJECTION VEDOLIZUMAB 1 MG
J3385	VELAGLUCERASE ALFA
J7312	DEXAMETHASONE INTRA IMPLANT
J7313	INJ FA INTRAVITREAL IMPL 0.01 MG
J7320	GENVISC 850 INJ 1MG
J7321	HYALGAN/SUPARTZ INJ PER DOSE
J7322	SYNVISC INJ PER DOSE
J7323	EUFLEXXA INJ PER DOSE
J7324	ORTHOVISC INJ PER DOSE
J7325	SYNVISC OR SYNVISC-ONE
J7326	GEL-ONE
J7327	MONOVISC INJ PER DOSE
J7328	HYAL/DERIVATV GEL-SYN IA INJ 0.1 MG
J9017	ARSENIC TRIOXIDE INJECTION
J9019	ERWINAZE INJECTION
J9022	INJECTION ATEZOLIZUMAB 10 MG
J9023	INJECTION AVELUMAB 10 MG
J9025	INJECTION AZACITIDINE 1 MG
J9027	INJECTION CLOFARABINE 1 MG
J9034	INJ. BENDEKA 1 MG
J9035	INJECTION BEVACIZUMAB 10 MG
J9039	INJECTION BLINATUMOMAB 1 MICROGRAM
J9041	INJECTION BORTEZOMIB 0.1 MG
J9042	BRENTUXIMAB VEDOTIN INJ
J9043	CABAZITAXEL INJECTION
J9047	INJECTION, CARFILZOMIB, 1 MG
J9055	INJECTION CETUXIMAB 10 MG
J9176	INJECTION ELOTUZUMAB 1MG
J9205	INJ IRINOTECAN LIPOSOME 1 MG
J9217	LEUPROLIDE ACETATE FOR DEPOT SUSPENSION 7.5 MG
J9225	VANTAS IMPLANT
J9226	SUPPRELIN LA IMPLANT
J9228	IPILIMUMAB INJECTION
J9261	INJECTION, NELARABINE, 50 MG
J9262	INJ, OMACETAXINE MEP, 0.01MG
J9264	INJECTION PACLITAXEL PROTEIN-BOUND PARTICLES 1 MG
J9266	PEGASPARGASE INJECTION
J9271	INJECTION PEMBROLIZUMAB 1 MG
J9280	MITOMYCIN INJECTION
J9285	INJECTION OLARATUMAB 10 MG
J9299	INJECTION NIVOLUMAB 1 MG
J9301	OBINUTUZUMAB INJ
J9303	PANITUMUMAB INJECTION
J9305	INJECTION PEMETREXED 10 MG
J9306	INJECTION, PERTUZUMAB, 1 MG
J9308	INJECTION RAMUCIRUMAB 5 MG
J9352	INJECTION TRABECTEDIN 0.1MG
J9354	INJ, ADO-TRASTUZUMAB EMT 1MG
J9355	TRASTUZUMAB INJECTION
J9395	INJECTION, FULVESTRANT, 25 MG
J9400	INJ, ZIV-AFLIBERCEPT, 1MG
J9999	NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUGS
Q0138	FERUMOXYTOL, NON-ESRD
Q2050	DOXORUBICIN INJ 10MG
Q5102	INJECTION, INFLIXIMAB, BIOSIMILAR, 10 MG
Q5103	INJECTION, INFLECTRA
Q5104	INJECTION, RENFLEXIS
Q5108	INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG
Q9989	USTEKINUMAB IV INJ, 1 MG
Q9991	BUPRENORPH XR 100 MG OR LESS
Q9992	BUPRENORPHINE XR OVER 100 MG
Q9993	INJ TRIAMCINOLONE EXT REL