Technical Coding Alignment for Prior Auth Processing of Select MIDs
Published Date: Mon, Jul 27, 2026 NEW
Effective Sept. 1, 2026, Highmark will align our technical coding with the intended configuration for prior authorization processing of the medical injectable drugs (MIDs) listed below. This ensures consistency with previously published prior authorization requirements. While widespread impact is not anticipated, variations in processing may occur based on the individual’s benefit plan, eligibility, group provisioning, and concurrent programs.
All initial authorization requests should be submitted through Availity Essentials, Highmark’s provider portal. Our prior authorization list is available on the Obtaining Authorizations page of the Provider Resource Center (PRC).
|
Code |
Terminology |
|---|
Q5157 |
INJECTION, DENOSUMAB-BMWO (STOBOCLO/OSENVELT), BIOSIMILAR, 1 MG |
Q5158 |
INJECTION, DENOSUMAB-BNHT (BOMYNTRA/CONEXXENCE), BIOSIMILAR, 1 MG |
Q5159 |
INJECTION, DENOSUMAB-DSSB (OSPOMYV XBRYK), BIOSIMILAR, 1 MG |
J9248 |
INJECTION, MELPHALAN (HEPZATO), 1 MG |
J9021 |
INJECTION, ASPARAGINASE, RECOMBINANT, (RYLAZE), 0.1 MG |
J9347 |
INJECTION, TREMELIMUMAB-ACTL, 1 MG (IMJUDO) |
J9272 |
INJECTION, DOSTARLIMAB-GXLY, 10 MG (JEMPERLI) |
J9011 |
INJECTION, DATOPOTAMAB DERUXTECAN-DLNK, 1 MG (DATROWAY) |
J9282 |
MITOMYCIN, INTRAVESICAL INSTILLATION, 1 MG (ZUSDURI) |
J9061 |
INJECTION, AMIVANTAMAB-VMJW, 2 MG (RYBREVANT) |
J9326 |
INJECTION, TELISOTUZUMAB VEDOTIN-TLLV, 1 MG (EMRELIS) |
Q5122 |
INJECTION, PEGFILGRASTIM-APGF, (NYVEPRIA), BIOSIMILAR, 0.5 MG |
J9227 |
INJECTION, ISATUXIMAB-IRFC, 10 MG (SARCLISA) |
J1448 |
INJECTION, TRILACICLIB, 1 MG (COSELA) |
J0224 |
INJECTION, LUMASIRAN, 0.5 MG (OXLUMO) |
Q5118 |
INJECTION, BEVACIZUMAB-BVZR, BIOSIMILIAR, (ZIRABEV), 10 MG |
J9038 |
INJECTION, AXATILIMAB-CSFR, 0.1 MG (NIKTIMVO) |
Member eligibility and benefits can be verified through Patient Registration feature in Availity. Plan-preferred products and Site of Care considerations may apply in line with member benefits. Please confirm the most up-to-date coverage criteria outlined in Highmark’s applicable Medical Policies, accessible via the PRC.
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