BCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015
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1 Prior Authorization List 2015 Participating providers are responsible to furnish or arrange health care services with other participating healthcare facilities or providers. Prior authorization requests are the responsibility of participating providers. Out-of-Network Services: for any referral to a non-participating health care facility or provider, for any outof-network services, the participating provider must first obtain prior authorization from BCBS AZ Adv. In-Network Services: For the in-network services listed below, the participating provider must first obtain prior authorization from BCBS AZ ADV: Ambulance Services (Non-Emergent) Bariatric Surgery only if performed outpatient or ASC Breast Reconstruction: Non-Mastectomy only if performed outpatient or ASC Cosmetic Procedures and Reconstructive Surgeries (e.g: Breast Reduction, Blepharoplasty, Strabismus, Panniculectomy) only if performed outpatient or ASC DME over $1,000 (EXCEPT for Premier Plan) Electrical Stimulation Procedures- All (e.g.: Brain, Bladder, Spine) only if performed outpatient or ASC Joint Replacement Surgeries (e.g.: Knee, Hip, Shoulder, Ankle) only if performed outpatient or ASC Outpatient Diagnostic (CT, MRI, MRA, PET) (BHN: See HealthHelp Information Below) Orthognathic Surgery only if performed outpatient or ASC Pain Management Specialist Services-(Ongoing After Initial Evaluation) Prosthetics/Orthotics/Medical Supplies Proton Beam Therapy Skilled Nursing Facility Stays Spinal Surgeries only if performed outpatient or ASC Transplants (Excludes Corneal) Vein Treatment or Procedures only if performed outpatient or ASC Medicare Part B Rx Drugs and Home Infusion Drugs (see attached list) For Banner Health Network Members All CT/CTA/MRI/MRA/PET - Submit to Health Help at Fax (800) ; Phone (800) ; Website: All services and procedures, regardless of place of service, must meet medical necessity criteria. For questions or more information, please call Blue Cross Blue Shield Arizona Advantage at:
2 Medicare Part B Rx Drugs and Home Infusion Drugs Requiring Prior Auth Brand Name Generic Name Applicable Code Neupogen Filgrastim J1442 Actemra tocilizumab J3262 Aldurazyme laronidase J1931 Aveed testosterone undecanoate, injection 1mg C9023 Blood Clotting Factors Antihemophiliac Products require prior authorization Alprolix factor ix (antihemophiliac factor, recombinant), Alprolix per 10 i.u. C9135 Wilate Willebrand factor/coagulation Factor VIII complex (Human) J7183 Alphanate VWF complex Von Willebrand Factor complex Human ristocetin Cofactor J7187 Corifact Injection, factor XIII (antihemophilic factor, human), 1 IU J7180 Xyntha Injection, factor VIII (antihemophilic factor, recombinant) (xyntha), J7185 per I.U. Injection, antihemophiliac factor VIII/ Von Willebrand factor J7186 complex Factor VIIa (antihemophilic factor, recombinant), per 1 microgram J7189 Monarc-M Factor VIII (anti-hemophilic factor, human) per IU J7190 Factor VIII (antihemophilic factor, recombinant) Per I.U. J7192 Factor IX (antihemophilic factor, purified, non-recombinant) per J7193 I.U. Konyne-80, Factor IX complex, per IU J7194 Profilnine Heat Treated, Proplex T, Proplex SX-T Factor IX (antihemophilic factor, recombinant) oer I.U. J7195 Injection, antithrombin recombinant, 50 I.U. J7196 Thrombate III Antithrombin III (human), per IU J7197 Anti-inhibitor, per IU J7198 Hemophilia clotting factor, not otherwise classified J7199 Aralast Alpha 1-proteinase inhibitor-human J0256 Avastin bevacizumab J9035 C9257 Benlysta Injection, belimumab, 10mg J0490 Berinert Injection, C-1 esterase inhibitor (human), 10 units J0597 Botox botulinum toxin type A J0585, J0586, J0588 Cerezyme injection, imiglucerase 10 units J1786 Cidofovir vistide 75mg J0740 Cimzia certolizumab J0718
3 Cinryze C1 esterase inhibitor (human) J0598 Elaprase idursulfase, 1mg J1743 Entyvio vedolizumab, injection 1mg C9026 Fabrazyme agalsidase beta J0180 Flolan injection, epoprostenol, 0.5mg J1325 Glassia alpha 1 proteinase, inhibitor (human), 10 mg J0257 Ilaris Injection, canakinumab, 1mg J0638 Intravenous Immune All IVIG requires prior authorization Globulin (IVIG) Carimune/Carimune NF Immune globulin, lyophilized (IVIG) J1566 Flebogamma Immune globulin, non-lyophilized (IVIG) J1572 Gammagard/Gammagard Immune globulin, lyophilized (IVIG) J1566 SD Gammagard liquid injection Immune globulin, non-lyophilized (IVIG), Gammagard liquid J1569 Gammaplex Immune globulin, non-lyophilized J1557 Gammar-P Immune globulin, lyophilized (IVIG) J1566 Gamunex Immune globulin, non-lyophilized (IVIG) J1561 Hizentra Immune globulin, (injection) J1559 Immune Globulin NOS Immune globulin, non-lyophilized (injection) J1599 Iveegam EN immune globulin, lyophilized (IVIG) Octegam Immune globulin, non-lyophilized (IVIG) J1568, Panglobulin/Panglobulin Immune globulin, lyophilized (IVIG) J1566 NF Privigen Immune globulin, non-lyophilized (liquid) 500mg (IVIG) 90283, J1459 Euflexxa hyaluronan or derivative J7323 Gel-One hyaluronan or derivative J7326 Hyalgan or Supartz hyaluronan or derivative J7321 Jetrea ocriplasmin 0.125mg J7316 Kalbitor ecallantide J1290 Krystexxa injection, pegloticase 1mg J2507 Makena injection, hydroxyprogesterone caproate, 1 mg J1725 Mozobil injection, plerixafor 1mg J2562 MyoBloc (Botulinum toxin type B) MyoBloc (Botulinum toxin type B) J0587 Myozyme alglucosidase Alpha, 10mg J0220, J0221 Lumizyme alglucosidase Alpha J0221
4 Naglazyme galsulfase J1458 Natrecor nesiritide, 0.1mg J2325 NPlate injection, romiplostim, 10mcg J2796 Nulojix nesiritide 0.1mg J0485 Orencia abatacept J0129 Orthovisc hyaluronan or derivative J7324 Prolastin Alpha 1-protenase inhibitor human J0256 Prolia denosumab J0897 Remicade infliximab J1745 Reclast zoledronic acid, 1mng J3489 Remodulin tresprostinil,inhalation solution J7686 Retisert fluocinolone acetonide, intravitreal implant J7311 Rituxan rituximab J9310 C9800 Simponi golimumab J3590 C9399 (IV) Simulect baxiliximal J0480 Solaris eculizumab injection J1300 Stelara ustekinumab J3357 Synvisc or Synvisc-One hyaluronan or derivative J7325 Tysabri natalizumab J2323 Vibativ injection, telavancin 10 mg J3095 Vimizim Injection, elosulfase alfa, 1mg C9022 Vpriv velaglucerase alfa J3385 Xeomin incobotulinumtoxina 1 unit J0588 Xgeva denosumab J0897 Xiaflex injection, collagenase clostridium histolyticum, 0.01 mg J0775 Xolair omalizumab J2357 Zemaira Alpha 1-proteinase inhibitor - human J0256 Zometa zoledronic acid Q2051, J3489 Vivitrol Naltrexone J2315 HP Acthar Gel Injection repository Corticotropin Inj J0800 Kineret Anakinra J3490, J3590 Multiple Sclerosis Injectable Therapy
5 Hepatitis C Injectable Therapy Injectafer Ferric Carboxymaltose J1439 Erythropoiesis- Stimulating Agents (ESAs) Procrit or Epogen Aranesp J0885 J0881
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