Added codes
Effective March 5, 2025
Non-covered Experimental/Investigational Services, 10.01.533 PBC | Premera HMO
Now
requires review for investigational.
92972
Effective February 7, 2025
Medical Necessity Criteria for Pharmacy Edits, 5.01.605 PBC | Premera HMO
Now requires
review for medical necessity and prior authorization.
J0850, J7351, 90291
Miscellaneous Oncology Drugs, 5.01.540 PBC | Premera HMO
Now requires review for medical
necessity and prior authorization.
J9034, J9036, J9056, J9153, J9266, J9268
Revised codes
Effective February 1, 2025
Alpha1-Proteinase Inhibitors, 5.01.624 PBC | Premera HMO
No longer requires review for site of service.
Review for medical necessity and prior authorization still required.
J0256
C3 and C5 Complement Inhibitors, 5.01.571 PBC | Premera HMO
No longer requires review for site of service.
Review for medical necessity and prior authorization still required.
J1300, J1303
Drugs for Rare Diseases, 5.01.576 PBC | Premera HMO
No longer requires review for site of service. Review
for medical necessity and prior authorization still required.
J0180, J0221, J0584, J1322, J1458, J1743, J1786, J1931, J2840, J3060, J3385, J3397
Hereditary Angioedema, 5.01.587 PBC | Premera HMO
No longer requires review for site of service. Review for
medical necessity and prior authorization still required.
J0598
IL-5 Inhibitors, 5.01.559 PBC | Premera HMO
No longer requires review for site of service. Review for medical
necessity and prior authorization still required.
J2786
Immune Checkpoint Inhibitors, 5.01.591 PBC | Premera HMO
No longer requires review for site of service. Review
for medical necessity and prior authorization still required.
J9271, J9299
Immune Globulin Therapy, 8.01.503 PBC | Premera HMO
No longer requires review for site of service. Review
for medical necessity and prior authorization still required.
J1459, J1551, J1552, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1599, 90283
Medical Pharmacologic Treatment of Multiple Sclerosis, 5.01.644 PBC | Premera HMO
No longer requires review
for site of service. Review for medical necessity and prior authorization still required.
J2323, J2329, J2350, Q5134
Nulojix (belatacept) for Adults, 5.01.536 PBC | Premera HMO
No longer requires review for site of service.
Review for medical necessity and prior authorization still required.
J0485
Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570 PBC | Premera HMO
No longer requires review
for site of service. Review for medical necessity and prior authorization still required.
J1426, J1428, J1429
Pharmacologic Treatment of Psoriasis, 5.01.629 PBC | Premera HMO
No longer requires review for site of service.
Review for medical necessity and prior authorization still required.
J1745, J1747, Q5103, Q5104, Q5121
Pharmacologic Treatment of Sickle Cell Disease, 5.01.640 PBC | Premera HMO
No longer requires review for
site of service. Review for medical necessity and prior authorization still required.
J0791
Pharmacotherapy of Arthropathies, 5.01.550 PBC | Premera HMO
No longer requires review for site of service.
Review for medical necessity and prior authorization still required.
J0129, J1602, J1745, J3247, J3262, Q5103, Q5104, Q5121, Q5133
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
No longer requires review for
site of service. Review for medical necessity and prior authorization still required.
J1745, J2323, J3380, Q5103, Q5104, Q5121, Q5134, J2327, J3358
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564 PBC | Premera HMO
No longer requires review
for site of service. Review for medical necessity and prior authorization still required.
J0129, J0490, J1745, J1823, J3262, Q5103, Q5104, Q5121, Q5133
Rituxan (rituximab): Non-oncologic and Miscellaneous, 5.01.556 PBC | Premera HMO
No longer requires review
for site of service. Review for medical necessity and prior authorization still required.
J9312, Q5115, Q5119, Q5123
Removed codes
Effective February 1, 2025
Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63 PBC | Premera HMO
Chimeric Antigen Receptor Therapy for Multiple Myeloma, 8.01.66PBC | Premera HMO
No longer requires review.
38225, 38226, 38227