CommercialNovember 1, 2023
Federal Employee Program specialty pharmacy prior authorization review
Effective for dates of service on or after February 1, 2024, the Federal Employee Program® (FEP) will require prior authorization (PA) review for the specialty drugs listed below. This applies to member IDs beginning with an “R”.
Prior to administering the drug(s) at any setting, PA must be completed to evaluate if the drug(s) meets clinical criteria. Care providers can request PA by calling FEP at 800-860-2156. Medications administered on or after February 1, 2024, without receiving PA will result in a denial of claims payment. If PA is denied for the drug not meeting medical necessity, care providers will follow the current disputed claim or service process.
FEP will continue to review the Federal Employee Medical Policy criteria for medical necessity on the drugs listed below. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits.
For more information, contact Provider Services by calling the number on the back of your patient’s member ID card, or contact FEP at 800-860-2156.
Product name | Codes | Therapeutic category
|
Alymsys | Q5126 | Bevacizumab |
Amvuttra | J0225 | Amyloidosis |
Avastin | J9035, C9257 | Bevacizumab |
Beovu | J0179 | Ocular VEGF |
Byooviz | Q5124 | Ocular VEGF |
Cimerli | Q5128 | Ocular VEGF |
Eylea | J0178 | Ocular VEGF |
Fulphila | Q5108 | Pegfilgrastim |
Fylnetra | Q5130 | Pegfilgrastim |
Givlaari | J0223 | AHP (Acute Hepatic Porphyria) |
Granix | J1447 | Filgrastim |
Herceptin | J9355 | Trastuzumab |
Herceptin Hylecta | J9356 | Trastuzumab |
Kanjinti | Q5117 | Trastuzumab |
Lucentis | J2778 | Ocular VEGF |
Mvasi | Q5107 | Bevacizumab |
Neulasta | J2506 | Pegfilgrastim |
Neulasta/Onpro | J2506 | Pegfilgrastim |
Neupogen | J1442 | Filgrastim |
Nivestym | Q5110 | Filgrastim |
Nyvepria | Q5122 | Pegfilgrastim |
Ogivri | Q5114 | Trastuzumab |
Onpattro | J0222 | Amyloidosis |
Ontruzant | Q5112 | Trastuzumab |
Oxlumo | J0224 | Primary Hyperoxaluria Type 1 |
Procrit | J0885 | Erythropoietin |
Releuko | Q5125 | Filgrastim |
Retacrit | Q5106 | Erythropoietin |
Riabni | Q5123 | Rituximab |
Rituxan | J9312 | Rituximab |
Rituxan Hycela | J9311 | Rituximab |
Rolvedon | J1449 | Eflapegrastim |
Ruxience | Q5119 | Rituximab |
Skyrizi | J2327 | Autoimmune |
Soliris | J1300 | Complement Inhibitors |
Stelara IV | J3358 | Autoimmune |
Stelara SQ | J3357 | Autoimmune |
Stimufend | Q5127 | Pegfilgrastim |
Tegsedi | C9399, J3490, J3590 | Amyloidosis |
Truxima | Q5115 | Trastuzumab |
Udenyca | Q5111 | Pegfilgrastim |
Vabysmo | J2777 | Ocular VEGF |
Vegzelma | Q5129 | Bevacizumab |
Vyvgart | J9332 | Antimyasthenic Agents |
Vyvgart Hytrulo | C9399, J3490, J3590 | Antimyasthenic Agents |
Zarxio | Q5101 | Filgrastim |
Ziextenzo | Q5120 | Pegfilgrastim |
Zirabev | Q5118 | Bevacizumab |
MULTI-BCBS-CM-041497-23-CPN41103
PUBLICATIONS: November 2023 Provider Newsletter
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