ATTENTION: Prior Authorization Update Effective 01/01/2018

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Jesse Stafford
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ATTENTION: Prior Authorization Update Effective 01/01/2018 Buckeye Health Plan requires prior authorization as a condition of payment for many services.

1 ATTENTION: Prior Authorization Update Effective 01/01/2018 Buckeye Health Plan 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 Buckeye Health Plan. Buckeye Health Plan 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 January 1, 2018, prior authorization will be required for Gender Reassignment, Genetic Counseling, X-STOP spinal surgery, Enhanced External Counterpulsation, Chondrocyte Implants, and Capsule Endoscopy. In addition, prior authorization requirements have been updated regarding Cosmetic/Dermatologic procedures and Part B Drugs which will also be effective January 1, Refer to the information below for guidance regarding how to obtain prior authorizations from Buckeye Health Plan. 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 [insert health plan website address] and clicking on the Prior Auth Needed tab. The Prior Auth Needed 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 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 The fax authorization form can be found on our website at You may call our Medical Management department at 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 or contact your dedicated Provider Relations Specialist. When the services below are Covered Services, the services require Prior Authorization. Prior Authorization will be required for these services effective January 1,

2 Gender Reassignment Procedures (*Require authorization with a Gender Reassignment Diagnosis) ADJACENT TISS TRANSF TRUNK; DEFECT 10 SQ CM/LESS ADJACENT TRANSF CHIN/NECK/AX/FT; 10 SQ CM/LESS ADJACENT TRANSF CHIN/NECK/AX/FT; SQ CM SPLIT GFT TRUNK; 1ST 100 SQ CM/1% BODY CHILD SPLIT GFT FACE; 1ST 100 SQ CM/LESS/1% BODY CHILD SPLIT GFT FACE; EA ADD 100 SQ CM/EA ADD 1% CHILD FULL THICK GFT-FREE-TRUNK; 20 SQ CM/LESS FORMATION DIR/TUBED PEDICLE W/WO TRANSF; TRUNK FORM DIR PEDICLE W/WO TRANSF; CHEEKS/CHIN/AX/FT DELAY FLAP/SECT FLAP; AT TRUNK DELAY FLAP/SECT FLAP; FOREHEAD/CHIN/AX/GENIT/FT FREE SKIN FLAP W/MICROVASC ANASTOM FREE FASCIAL FLAP W/MICROVASC ANASTOM MASTECTOMY, SIMPLE, COMPLETE MASTECTOMY, SUBCUTANEOUS COLECTOMY PART; W/COLOPROCTOSTOMY URETHROPLASTY 1-STAGE RECON MALE ANT URETHRA URETHROPLASTY 1 STAGE RECON PROSTATIC URETHRA URETHROPLASTY 2-STAGE RECON URETHRA; 1ST STAGE URETHROPLASTY, 2-STAGE RECON URETHRA; 2ND STAGE URETHROPLASTY RECON FE URETHRA URETHROMEATOPLASTY W/PART EXC DISTAL URETHRL SEG AMPUTA PENIS; COMPLT INSRT PENILE PROSTH; NON-INFLATABLE INSRT PENILE PROSTH; INFLATABLE INSRT INFLATBL PENILE PROSTH W/PLCMT PUMP/CYLIND ORCHIECTOMY SIMPL W/WO TESTICULAR PROSTH INSRT TESTICULAR PROSTH (SEPART PROC) LAPAROSCOPY ORCHIECTOMY SCROTOPLASTY; SIMPL SCROTOPLASTY; COMPLIC VULVECTOMY SIMPL; COMPLT PLASTIC REPR INTROITUS CLITOROPLASTY INTERSEX STATE PERINEOPLASTY REPR PERINEUM NON-OB (SEPART PROC) VAGINECTOMY PART REMOV VAG WALL; VAGINECT PART REMOV VAG WALL; REMOV PARAVAG TISS VAGINECT COMPLT REMOV VAG WALL; VAGINECT COMPLT REMOV VAG WALL; REMOV PARAVAG CONSTRUCTION ARTIFICIAL VAG; WO GFT CONSTRUCTION ARTIFICIAL VAG; W/GFT VAGINOPLASTY INTERSEX STATE 2

3 Genetic Counseling TOT ABD HYST W/WO REMOV TUBE(S) - OVARY(S) SUPRACERV ABD HYST W/WO REMOV TUBE(S) - OVARY(S) VAG HYST UTERUS 250 GRAMS OR LESS; VAG HYST UTRUS 250 GMS/<; REMV T&/O VAG HYST UTRUS 250 GM/<;REP ENTERCL VAG HYST 250 GM/<;CLPO-URTHRCYSTPXY VAG HYST UTRUS 250 GM/<;REP ENTROCL VAG HYST W/TOT/PART COLPECTOMY VAG HYST W/TOT/PART COLPECTOMY; W/REPR ENTEROCEL VAG HYST RADICAL VAG HYST UTERUS > 250 GRAMS; VAG HYST UTRUS>250 GMS; REMV T&/O VAG HYST UTRUS>250 GM; T&/O ENTROCL VAG HYST UT>250 GM;CLPO-URTHRCYSTPX VAG HYST UTRUS >250 GM;REP ENTEROCL LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, UTERUS 250 G OR LESS WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) LAP, SURG, SUPERACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) LAP SURG VAG HYST UTRUS 250 GMS/<; LAP VAG HYST UTRUS 250 GMS/<; T&/O LAP W/VAG HYST UTRUS > 250 GMS; LAP VAG HYST UTRUS>250 GM;REMV T&/O TLH UTERUS 250 G OR LESS TLH W/T/O 250 G OR LESS TLH UTERUS OVER 250 G TLH W/T/O UTERUS OVER 250 G LAPAROSCOPY SURGICAL REMOVAL ADNEXAL STRUCTURES SALPINGO-OOPHORECTOMY COMPLT/PART (SEPART PROC) OOPHORECTOMY PART/TOT UNILAT/BILAT Gender Reassignment Procedures (*Always requires authorization) INTERSEX SURGERY, MALE TO FEMALE INTERSEX SURGERY, FEMALE TO MALE Genetic Counseling S0265 GENETIC COUNSELING, UNDER PHYSICIAN SUPERVISION, EACH 15 MIN GENETIC COUNSELING, 30 MIN 3

4 Genetic Counseling INJ., INTRALESIONAL TO & INC.7 LES INJ. INTRALESIONAL, MORE THAN 7 LES TATOOING/COLOR DFCTS SKN TO 6 SQ CM TATOOING/COLOR DFCT SKN 6-20 SQ CM TATOOING/COLOR DFCT SKN OV 20 SQ CM INSERTION TISSUE EXPANDER(S) OTHER THAN BREAST,INCLUD. SUBSEQ. EXPANS REPLACE TISSUE EXP C PERM PROS REMVE TIS EXPNDR W/O INSR OF PROSTH IMPLANT HORMONE PELLET(S) DESTRUCT CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; LESS THAN 10 SQ.CM DESTRUCT CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; SQ. CM DESTRUCT CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; OVER 50.0 SQ. CM. X-STOP Spinal Surgery 0171T LUMBAR SPINE PROCES DISTRACT UNLSTD PROC SPINE Enhanced External Counterpulsation (EECP) CARDIOASSIST-METHOD, EXTERNAL G0166 EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION Chondrocyte Implants AUTOCHONDROCYTE IMPLANT KNEE OSTEOCHONDRAL KNEE AUTOGRAFT AUTGRFT IMPLNT, KNEE W/SCOPE ALLGRFT IMPLNT, KNEE W/SCOPE J7330 AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT S2112 ARTHROSCOPY, KNEE, SURGICAL FOR HARVESTING OF CARTILAGE (CHONDROCYTE CEL Capsule Endoscopy GI TRACT CAPSULE ENDOSCOPY ESOPHAGEAL CAPSULE ENDOSCOPY GI WIRELESS CAPSULE MEASURE Medicare Part B Drugs C9130 INJ IMMUNE GLOBULIN BIVIGAM 500 MG C9133 FACTOR IX RECOMBINANT C9134 FACTOR XIII A-SUBUNIT RECOMB C9136 FACTOR VIII (ELOCTATE) C9137 ADYNOVATE FACTOR VIII RECOM 4

5 C9138 C9139 C9140 C9399 C9399 C9473 C9481 C9484 J0129 J0135 J0178 J0180 J0202 J0220 J0220 J0221 J0221 J0256 J0256 J0256 J0257 J0257 J0257 J0257 J0270 J0364 J0490 J0570 J0585 J0585 J0586 J0586 J0586 J0587 J0587 J0587 J0588 J0588 J0598 J0630 J0638 J0718 J0800 J0881 NUWIQ FACTOR VIII RECOMB IDELVION 1 IU AFSTYLA FACTOR VIII RECOMB OR BIOLOGICALS OR BIOLOGICALS INJECTION, MEPOLIZUMAB INJECTION RESLIZUMAB INJECTION ETEPLIRSEN 10 MG ABATACEPT INJECTION INJECTION, ADALIMUMAB, 20 MG AFLIBERCEPT INJECTION INJECTION, AGALSIDASE BETA, 1 MG INJECTION ALEMTUZUMAB 1 MG ALGLUCOSIDASE ALFA INJECTION ALGLUCOSIDASE ALFA INJECTION LUMIZYME INJECTION LUMIZYME INJECTION ALPHA 1 PROTEINASE INHIBITOR ALPHA 1 PROTEINASE INHIBITOR ALPHA 1 PROTEINASE INHIBITOR GLASSIA INJECTION GLASSIA INJECTION GLASSIA INJECTION GLASSIA INJECTION ALPROSTADIL, PER 1.25MCG INJECTION APOMORPHINE HYDROCHLORIDE 1 MG BELIMUMAB INJECTION BUPRENORPHINE IMPLANT 74.2MG INJECTION,ONABOTULINUMTOXINA INJECTION,ONABOTULINUMTOXINA ABOBOTULINUMTOXINA ABOBOTULINUMTOXINA ABOBOTULINUMTOXINA INJ, RIMABOTULINUMTOXINB INJ, RIMABOTULINUMTOXINB INJ, RIMABOTULINUMTOXINB INCOBOTULINUMTOXIN A INCOBOTULINUMTOXIN A C-1 ESTERASE, CINRYZE INJECTION, CALCITONIN SALMON, UP TO 400 UNITS CANAKINUMAB INJECTION CERTOLIZUMAB PEGOL INJ INJECTION, CORTICOTROPIN, UP TO 40 UNITS INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) 5

6 J0882 J0885 J0886 J0888 J0894 J1110 J1300 J1324 J1438 J1442 J1443 J1458 J1459 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1595 J1599 J1602 J1610 J1645 J1652 J1675 J1744 J1745 J1786 J1817 J1825 J1931 J2170 J2182 J2212 J2315 J2323 J2354 J2355 J2357 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYS INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS) EPOETIN BETA NON ESRD INJECTION DECITABINE 1 MG INJECTION, DEHYDROERGOTAMINE, UP TO 1 MG ECULIZUMAB INJECTION ENFUVIRTIDE INJECTION INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG AD INJ FILGRASTIM EXCL BIOSIMIL INJ FERRIC PRPP CIT SOL 0.1 MG IRON INJECTION GALSULFASE 1 MG INJ IVIG PRIVIGEN 500 MG INJ, IMM GLOB BIVIGAM, 500MG GAMMAPLEX INJECTION HIZENTRA INJECTION GAMUNEX-C/GAMMAKED INJECTION; IMMUNE GLOBULIN 10%, 5 GRAMS INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P OCTAGAM INJECTION GAMMAGARD LIQUID INJECTION FLEBOGAMMA INJECTION INJ IG/HYALURONIDASE 100 MG IG INJECTION, GLATIRAMER ACETATE, 20 MG IVIG NON-LYOPHILIZED, NOS GOLIMUMAB FOR IV USE 1MG INJECTION; GLUCAGON HYDROCHLORIDE INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS ICATIBANT INJECTION INJ INFLIXIMAB EXCL BIOSIMILR 10 MG IMUGLUCERASE INJECTION INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS INJECTION, INTERFERON BETA-1A, 33 MCG INJECTION, LARONIDASE, 0.1 MG MECASERMIN INJECTION INJECTION MEPOLIZUMAB 1MG METHYLNALTREXONE INJECTION INJECTION NALTREXONE DEPOT FORM 1 MG NATALIZUMAB INJECTION INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS IN INJECTION, OPRELVEKIN, 5 MG INJECTION, OMALIZUMAB, 5 MG 6

7 J2440 J2503 J2505 J2507 J2778 J2786 J2793 J2796 J2820 J2940 J2941 J3030 J3110 J3140 J3262 J3285 J3357 J3385 J3396,J3590orJ9999 J3590 J3590 J3590,C9399 J7175 J7179 J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7188 J7189 J7190 J7191 J7192 J7193 J7194 INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PEGAPTANIB SODIUM, 0.3 MG INJECTION, PEGFILGRASTIM, 6 MG PEGLOTICASE INJECTION RANIBIZUMAB INJECTION INJECTION RESLIZUMAB 1MG RILONACEPT INJECTION ROMIPLOSTIM INJECTION INJECTION, SARGRAMOSTIM (CM-CSF), 50 MCG INJECTION, SOMATREM, 1 MG INJECTION, SOMATROPIN, 1 MG INJECTION; SUMATRIPTAN SUCCINATE; 6MG INJECTION, TERIPARATIDE, 10 MCG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG TOCILIZUMAB INJECTION INJECTION, TREPROSTINIL, 1 MG USTEKINUMAB FOR SUBQ INJECTION 1 MG VELAGLUCERASE ALFA INJECTION, VERTEPORFIN, 0.1 MG MISCELLANEOUS CODES UNCLASSIFIED BIOLOGICS UNCLASSIFIED BIOLOGICS MISCELLANEOUS CODES INJ FACTOR X (HUMAN) 1IU VONVENDI INJ 1 IU VWF:RCO FACTOR XIII ANTI-HEM FACTOR FACTOR XIII RECOMB A-SUBUNIT FACTOR VIII RECOMB NOVOEIGHT WILATE INJECTION XYNTHA INJ ANTIHEMOPHILIC VIII/VWF COMP INJECTION VON WILLEBRAND FACTOR COMPLEX HUMAN RISTOCETIN COFACTOR PER IV INJECTION FACTOR VIII PER I.U. FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICR FACTOR VIII, (ANTI-HEMOPHILIC FACTOR (HUMAN)), PER I.U. FACTOR VIII (PORCINE) FACTOR VIII RECOMBINANT NOS FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U. FACTOR IX, COMPLEX, PER I.U. 7

8 J7195 J7196 J7197 J7198 J7199 J7200 J7201 J7202 J7207 J7209 J7518 J7527 J7639 J7686 J7799 J8501 J8565 J8650 J8705 J9010 J9015 J9212 J9213 J9214 J9215 J9216 J9218 J9310 Q0162 Q0515 Q2026 Q2027 Q2028 Q2043 Q2044 Q3025 Q3026 Q3027 Q4074 S0145 S0162 FACTOR IX RECOMBINANT NOS ANTITHROMBIN RECOMBINANT ANTITHROMBIN III (HUMAN), PER I.U. ANTI-INHIBITOR, PER I.U. HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED FACTOR IX RECOMBINAN RIXUBIS INJ FACTOR IX FC FUS PROTEIN PER IU FACTOR IX IDELVION INJ FACTOR VIII PEGYLATED RECOMB FACTOR VIII NUWIQ RECOMB 1IU MYCOPHENOLIC ACID, ORAL, 180 MG ORAL EVEROLIMUS DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE F TREPROSTINIL, NON-COMP UNIT NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME APREPITANT, ORAL, 5 MG GEFITINIB, ORAL, 250 MG NABILONE, ORAL TOPOTECAN ORAL ALEMTUZUMAB, 10 MG ALDESLEUKIN/SINGLE USE VIAL INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU INTERFERON, GAMMA 1-B, 3 MILLION UNITS LEUPROLIDE ACETATE, PER 1 MG RITUXIMAB, 100 MG ONDANSETRON ORAL INJECTION, SERMORELIN ACETATE, 1 MICROGRAM RADIESSE INJECTION SCULPTRA INJECTION INJ, SCULPTRA, 0.5MG SIPLEUCEL-T AUTO CD54+ BELIMUMAB INJECTION INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE INJ BETA INTERFERON IM 1 MCG ILOPROST NON-COMP UNIT DOSE INJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER ML INJECTION, EFALIZUMAB, 125 MG 8

9 Cosmetic/Dermatologic Procedures INJ., INTRALESIONAL TO & INC.7 LES INJ. INTRALESIONAL, MORE THAN 7 LES TATOOING/COLOR DFCTS SKN TO 6 SQ CM TATOOING/COLOR DFCT SKN 6-20 SQ CM TATOOING/COLOR DFCT SKN OV 20 SQ CM INSERTION TISSUE EXPANDER(S) OTHER THAN BREAST,INCLUD. SUBSEQ. EXPANS REPLACE TISSUE EXP C PERM PROS REMVE TIS EXPNDR W/O INSR OF PROSTH IMPLANT HORMONE PELLET(S) DESTRUCT CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; LESS THAN 10 SQ.CM DESTRUCT CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; SQ. CM DESTRUCT CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; OVER 50.0 SQ. CM. 9

MedStar Select Pharmacy Services

Pharmacy Services 1 MedStar Select Pharmacy Services Table of Contents At a Glance..page 2 Obtaining Prior Authorization for Medically Covered Medications..page 2 Pharmacy Services 2 At a Glance Welcome