October 2020
Medicaid Update: Prior Authorization Vendor Change for Select Medical Drug Codes
Effective July 1, 2020, in accordance with Illinois Department of Health and Family Services (HFS) requirements, Blue Cross and Blue Shield of Illinois (BCBSIL) made changes to the utilization management and claims process for a select group of medical drug service codes when these drugs are requested for our Blue Cross Community Health PlansSM (BCCHPSM) members.
The list of Current Procedural Terminology (CPT®) codes affected by this change is included below.* Previously, for these codes, prior authorization and claim submission through our pharmacy benefit management vendor, Prime Therapeutics, was required. There are no changes to the list of codes requiring prior authorization, but the utilization management vendor has changed.
- Effective immediately, prior authorization requests and claims for BCCHP members should no longer be submitted to Prime for the specified codes.
- For these codes, prior authorization through eviCore healthcare (eviCore) is required for BCCHP members.
- Upon completion of the prior authorization process, BCCHP member claims for these codes must be submitted to BCBSIL.
| CPT Code | Description | Prior Authorization Vendor (for BCCHP Members) |
| 90281 | HUMAN IG IM | Effective July 1, 2020, prior authorization through eviCore is required for these CPT codes prior to rendering services for BCCHP members. You may submit prior authorization requests online via the eviCore Web Portal, or by calling eviCore at 855-252-1117. |
| 90283 | HUMAN IG IV | |
| 90284 | HUMAN IG SC | |
| 90378 | RSV MAB IM 50MG | |
| C9257 | Injection, bevacizumab, 0.25 mg | |
| J0585 | Injection, onabotulinumtoxina, 1 unit | |
| J0586 | Injection, abobotulinumtoxina, 5 units | |
| J0587 | Injection, rimabotulinumtoxinb, 100 units | |
| J0588 | Injection, incobotulinumtoxin a, 1 unit | |
| J0800 | Injection, corticotropin, up to 40 units | |
| J0888 | Injection, epoetin beta, 1 microgram, (for non ESRD use) | |
| J1602 | Injection, golimumab, 1 mg, for intravenous use | |
| J1745 | Injection infliXimab, 10 mg | |
| J2357 | Injection, omalizumab, 5 mg | |
| J2502 | Injection, pasireotide long acting, 1 mg |
Support and More Information
The 2020 Medicaid Benefit Preauthorization Procedure Code List on our Provider website has been updated to reflect the vendor change referenced above. Please note that updates to some systems are still in progress. For example, when you submit eligibility and benefits requests to BCBSIL (online or by calling our automated phone system), you may continue to be instructed to contact Prime for prior authorization. To assist with the transition, if you contact Prime, they will redirect applicable prior authorization requests to eviCore. If you already have a prior authorization in place with Prime, you don’t need to submit another request through eviCore. Extensions to existing requests and new requests should be submitted to eviCore.
Continue to watch the News and Updates for announcements and related resources. Updates also may be published in the Blue Review. If you have questions, contact your BCBSIL Provider Network Consultant (PNC) team.
*This list is not exhaustive. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.
CPT copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Please note that the fact that a service or treatment has been preauthorized for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, call the number on the member’s ID card.
BCBSIL contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. eviCore is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. eviCore is wholly responsible for its own products and services. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.