Authorization Updates

During the year, Highmark adjusts the List of Procedures and Durable Medical Equipment (DME) Requiring Authorization. For information regarding authorizations required for a member’s specific benefit plan, providers may:

  • Call the number on the back of the member’s card,
  • Check the member’s eligibility and benefits via Availity® NaviNet®, or
  • Search BlueExchange through the provider’s local provider portal.

These changes are announced in the form of Special Bulletins and other communications posted on Highmark’s Provider Resource Center (PRC). The most recent updates regarding Highmark’s prior authorization list are below:

  • CPT 37735 Ligation Procedures on Arteries and Veins was removed from the prior auth list.
  • J0172 (Adulhelm) and J0174 (Leqembi) moved to the Medical Injectables Site of Care Program.
  • Drugs — which received new codes — moved from the Not Otherwise Classified (NOC) section to the appropriate category in Medical Injectables:
    • J0217 - Lamzede
    • J2508 - Elfabrio
    • J3401 - Vyjuvek
    • J1304 - Qalsody
    • J1412 - Roctavian
    • J1413 - Elevidys
    • J9333 - Rystiggo
    • J9334 - Vyvgart Hytrulo
    • J9321 - Epkinly
    • J9286 - Columvi

See also the Special Bulletin detailing upcoming changes.