Medicare AdvantageJune 17, 2025
Specialty pharmacy precertification list expansion — key updates
Effective for dates of service on and after October 1, 2025, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.
Federal and state laws, along with state contract language and CMS guidelines — including definitions and specific contract provisions or exclusions — take priority over these precertification rules and must be considered first when determining coverage.
Note: Ensuring compliance with the new requirements will help facilitate claim approval.
HCPCS or CPT® codes | Medicare Part B drugs |
J3590 | Alhemo (concizumab‑mtci) |
C9399, J9999 | Datroway (datopotamab deruxtecan‑dlnk) |
C9399, J9999 | Grafapex (treosulfan) |
C9399, J9999 | Opdivo Qvantig (nivolumab hyaluronidase‑nvhy) |
C9399, J3590 | Steqeyma (ustekinumab‑stba) |
C9399, J9999 | Unloxcyt (cosibelimab‑ipdl) |
J3590 | Yesintek (ustekinumab‑kfce) |
C9302 | Ziihera (zanidatamab‑hrii) |
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWI), Compcare Health Services Insurance Corporation (Compcare), and Wisconsin Collaborative Insurance Company (WCIC). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CR-082709-25-CPN81629
PUBLICATIONS: July 2025 Provider Newsletter
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