HCPCS J8499 is officially defined as "Prescription drug, oral, non chemotherapeutic, nos." HCPCS J8499 is referenced in 11 tracked payer policy changes from Sentara Health Plans, WellCare, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J8499 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Beginning January 1, 2026, the procedure codes in this Centene bulletin require prior authorization through Evolent, which manages prior authorizations for Centene in medical oncology, radiation oncology, pediatric and dose optimization, and cardiology. The change applies to all Ambetter (Marketplace), Medicaid and Medicare products offered by Centene. The code table includes anti-emetics, bone metastasis drugs, cancer treatment drugs, and supportive medications such as iron products, ESAs, myeloid growth factors and immune globulins.
Aetna updated their National Precertification List with multiple new drug requirements and removed precertification for BRCA genetic testing. Several new specialty drugs now require precertification with staggered effective dates from March through April 2025, and new claim edits will be implemented starting July 1, 2025.
Prior authorization is required for the pulmonary arterial hypertension medications in this policy, and the requested medication may be considered medically necessary when all initial criteria are met. For pulmonary arterial hypertension (WHO Group 1), the criteria include right heart catheterization confirmation with mean pulmonary arterial pressure greater than 20 mmHg, pulmonary capillary wedge pressure less than 15 mmHg, and pulmonary vascular resistance of at least 2 Wood units, along with WHO functional class II or greater. Winrevair (sotatercept-csrk) is considered not medically necessary because its place in therapy has not yet been addressed in clinical practice guidelines, and Opsynvi (macitentan-tadalafil), Tadliq (tadalafil oral suspension), Tyvaso DPI (treprostinil inhalation powder) and Yutrepia (treprostinil inhalation powder) are considered not medically necessary as other formulary options exist.
Effective 09/01/2025, this BCBSMS policy separated opioid medications considered medically necessary without prior authorization from those that require prior authorization, and added renewal evaluation criteria. Opioids are considered medically necessary without prior authorization for one initial 7-day supply of immediate-release or short-acting opioid under 50 MME/day, an additional 7-day supply under 50 MME/day within 60 days of the original prescription, chronic cancer pain due to an active malignancy at no more than 50 MME/day, or as part of an end of life treatment plan. All other clinical scenarios require prior authorization, and Dsuvia is not currently covered on any BCBSMS formulary.
Jynarque (tolvaptan) requires prior authorization. Under the initial criteria, the individual must be 18 years of age or older and have autosomal dominant polycystic kidney disease (ADPKD), must not have stage 5 chronic kidney disease (CKD), must not be on dialysis, must not use the requested agent with another tolvaptan agent, and the prescriber must be a specialist or have consulted with one. The policy history records a 05/26/2026 Pharmacy & Therapeutics revision that removed the documented diagnosis and clinical improvement requirement from the initial and renewal criteria.
Otezla (apremilast) and Otezla XR require prior authorization and may be considered medically necessary for active psoriatic arthritis, plaque psoriasis, or Behcet's Disease when all listed criteria are met, with approval for 12 months. The 10/21/2026 update removed the requirement to document active psoriatic arthritis, plaque psoriasis and Behcet's Disease in the initial criteria and added cyclosporine to the conventional agents used for psoriatic arthritis. Program quantity limits are 60 tablets per 30 days for Otezla 20 mg and 30 mg and 30 tablets per 30 days for Otezla XR 75 mg.
BCBSMS requires prior authorization for the chronic hepatitis C agents in this policy: Epclusa, Harvoni, Mavyret, Pegasys, ribavirin, Sovaldi, Vosevi and Zepatier. The Pharmacy & Therapeutics Committee approved the policy on 12/02/2025 with minor description changes and updated criteria regarding hepatitis B virus. The 01/14/2025 revision removed Copegus, PEG-Intron, Rebetol, Ribapak, Ribasphere and Viekira Pak and is stated as effective 03/15/2025.
Koselugo (selumetinib) requires prior authorization. It may be considered medically necessary for individuals 1 year of age or older who are symptomatic and have inoperable plexiform neurofibromas from neurofibromatosis type 1, when the policy criteria are met. For oral granules, body surface area must be 0.40 m2 or greater and the individual must have difficulty swallowing capsules, and the policy was updated on 06/08/2026 regarding requests for oral granules.
Prior authorization is required for the multiple sclerosis drugs in this policy. Step 1 generic preferred agents are dimethyl fumarate, fingolimod, glatiramer and teriflunomide. Step 2 brand agents require trial and failure of one Step 1 agent, except Lemtrada, which requires trial and failure of two Step 1 or Step 2 agents with one of them a Step 1 agent, and Ocrevus products, which do not require it for primary progressive MS. Bafiertam, Briumvi, Copaxone, Mavenclad, Mayzent, Ponvory, Tascenso ODT, Tecfidera and Vumerity are not covered on any BCBSMS formulary. A 10/05/2026 update combined the medical covered agents into one Preferred Agents table, added Rebif Rebidose as a Step 2 brand preferred agent, and removed the renewal clinical improvement requirement for all agents except Ampyra.
Effective July 1, 2017, CPT 81287 no longer requires prior authorization for BlueCHiP for Medicare and Commercial products, and it is covered for BlueCHiP for Medicare but not medically necessary for Commercial products. Effective July 1, 2017, CPT 81545 requires prior authorization for Commercial products, and CPT 97607 and 97608 are not medically necessary for Commercial products. Effective September 1, 2017, the claim will be rejected if CMS-1500 boxes 17 and 17b do not contain the ordering provider's name and NPI for diagnostic laboratory, imaging, diagnostic tests, durable medical equipment and home infusion claims.
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