Medical Benefit Medication Prior Authorization
`Ohana Health Plan is committed to continuously improving its medical benefit medication claims review and prior authorization processes. Effective 09/01/2020, we will introduce new Pharmacy Prior Authorization Coding Guidelines based on required authorization standards, coding rules published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT®) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS).
Please see the table below for the recent updated to the prior authorization guidelines.
| HCPCS Code | Prior Auth Required? | Description |
|---|---|---|
|
J7296 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
J7345 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
J2787 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
J2186 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
J1095 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
J1130 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
J0884 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
Q9991 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
Q9992 |
N |
Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information. |
|
J9023 |
Y |
This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization via the HeathHelp website (https://portal.healthhelp.com/landing/?p=ED090C587BF7817C), call 888-210-3736 or fax 888-210-3769 |
|
J1627 |
Y |
This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization via the HeathHelp website (https://portal.healthhelp.com/landing/?p=ED090C587BF7817C), call 888-210-3736 or fax 888-210-3769 |
|
J9285 |
Y |
This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization via the HeathHelp website (https://portal.healthhelp.com/landing/?p=ED090C587BF7817C), call 888-210-3736 or fax 888-210-3769 |
|
J9203 |
Y |
This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization via the HeathHelp website (https://portal.healthhelp.com/landing/?p=ED090C587BF7817C), call 888-210-3736 or fax 888-210-3769 |
|
J9022 |
Y |
This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization via the HeathHelp website (https://portal.healthhelp.com/landing/?p=ED090C587BF7817C), call 888-210-3736 or fax 888-210-3769 |
|
J9044 |
Y |
This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization via the HeathHelp website (https://portal.healthhelp.com/landing/?p=ED090C587BF7817C), call 888-210-3736 or fax 888-210-3769 |
|
J7175 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J7179 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J7209 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J7210 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J7211 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J7320 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
Q5105 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
Q5106 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J1428 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
Q5103 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
Q5104 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
Q5108 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
Q5110 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
Q5111 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J1555 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J1729 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J1726 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J2350 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J0606 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J0604 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J2326 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J3358 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
|
J0565 |
Y |
This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal. |
Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case.
The proper reporting of CPT® procedure codes enables `Ohana Health Plan to more precisely apply reimbursement guidelines and ensure that an accurate record of patient care history is maintained.
Thank you for helping `Ohana Health Plan members live better, healthier lives.
If you have any questions or need further information, please contact `Ohana Provider Services at 1-888-846-4262 (TTY 711).
PRO_56295E Internal/State Approved 05282020 HI9PROLTR56295E_0000
