Priority Health: Beovu Payer Policy (Beta Access)
TABLE OF CONTENTS
MEDICARE PART B
HCPCS Code(s): | J0179 |
Precertification Required? | Dependent |
Step Therapy Required? | Not Specified |
Provider Fax Form: | Medicare Part B Medical Drug Request(✅ Available in SamaCare) |
FDA Approved Indications: | Not Specified |
Recommended Dosage: | Not Specified |
No PA required when billed for the following ICD-10 code: |
H35.3210-H35.3213, H35.3220-H32.3223, H35.3230-H35.3233, H35.3290-H35.3293 |
All other ICD-10 diagnoses: PA required |
Sources:
https://priorityhealth.stylelabs.cloud/api/public/content/Medical_Benefit_Drug_List_downloadOriginal?v=ebe3fbe9
MEDICAID
HCPCS Code(s): | J0179 |
Precertification Required? | Dependent |
Step Therapy Required? | Not Specified |
Provider Fax Form: | Medicaid Medical Drug Request (✅ Available in SamaCare) |
FDA Approved Indications: | Not Specified |
Recommended Dosage: | Not Specified |
No PA required when billed for the following ICD-10 code: |
H35.3210-H35.3213, H35.3220-H32.3223, H35.3230-H35.3233, H35.3290-H35.3293 |
Sources:
COMMERCIAL
HCPCS Code(s): | J0179 |
Precertification Required? | Dependent |
Step Therapy Required? | Not Specified |
Provider Fax Form: | Commercial Medical Drug Request (✅ Available in SamaCare) |
FDA Approved Indications: | Not Specified |
Recommended Dosage: | Not Specified |
No PA required when billed for the following ICD-10 code: |
H35.3210-H35.3213, H35.3220-H32.3223, H35.3230-H35.3233, H35.3290-H35.3293 |
Sources:
https://priorityhealth.stylelabs.cloud/api/public/content/Medical_Benefit_Drug_List_downloadOriginal?v=ebe3fbe9
⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval.
Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.
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