Effective November 1, 2018, prior authorization (PA) requirements will change for Part B injectable/infusible drugs Azedra (iobenguane I 131) and Poteligeo (mogamulizumab) to be covered by Anthem Blue Cross for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

  • Azedra (iobenguane I 131) — for treatment of malignant pheochromocytoma and paraganglioma (J3490, J9999)
  • Poteligeo (mogamulizumab) — for treatment of patients with cutaneous T-cell lymphoma (CTCL) who have received at least one prior systemic therapy (J3490, J9999)

 

Please note, the drugs noted above are currently billed under the not otherwise classified (NOC) HCPCS code J3490, J9999; they are unlisted because no J code has been established at this time. Since these codes include all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS code.

 

To request PA, you may use one of the following methods:

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call one of our Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County) for PA requirements.



Featured In:
August 2018 Anthem Blue Cross Provider Newsletter - California