Effective for dates of service on and after November 1, 2022, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of a national drug code on your medical claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below:

 

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

ING-CC-0205

J9331

Fyarro (sirolimus albumin bound)

ING-CC-0206

J3490, J3590

BESREMi (ropeginterferon alfa-2b-njft)

ING-CC-0207

J9332

Vyvgart (efgartigimod alfa-fcab)

ING-CC-0208

J3490

Adbry (tralokinumab)

ING-CC-0209

J3490

Leqvio (inclisiran)

Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

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CABC-CD-004131-22



Featured In:
September 2022 Anthem Blue Cross Provider News - California