The Health Plan requires authorization for various medically billable drug Current Procedural Terminology (CPT) codes (J codes) prior to performing a procedure or service effective April 15, 2019. Medically billable drugs are predominantly injectable or infusion drugs that are submitted on a medical claim and are reimbursed based on the member’s medical benefit rather than their pharmacy benefit. This affects all lines of business with The Health Plan: Commercial (including HMO, PPO and POS plans), WV Medicaid (including Mountain Health Trust, WV Health Bridge and SSI), Self-funded and Medicare (including SecureCare, SecureChoice, DSNP and Supplemental plans).

A summarized listing of CPT codes requiring prior authorization may be found on The Health Plan’s provider portal at https://myplan.healthplan.org. Authorization requirements may vary by member contract and are separated into three files Medicaid, Medicare, and Commercial/Self-Funded Plans. This is not an all-inclusive list. If you are unable to verify if a drug code requires prior authorization please contact The Health Plan. (This information should not be relied on as authorization for health care services and is not a guarantee of payment). 

The ordering provider is typically responsible for obtaining authorizations for the medically billable drug included on the list requiring prior authorization. Prior authorization may be requested electronically via The Health Plan’s password secure provider portal at https://myplan.healthplan.org.

The procedure codes contained on the list requiring prior authorization and related effective dates are subject to change. As this list will be fluid, The Health Plan will provide notice when codes are added/deleted/changed via online provider portal announcements.

Questions or concerns may be directed to The Health Plan Pharmacy Department at 1.800.624.6961, ext. 7914 or to the provider engagement representative assigned to your county. Please visit https://www.healthplan.org/providers to view the provider engagement territory map to locate contact information for your representative.