Jun 1, 2021 • State & Federal / Medi-Cal Managed Care

Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of NDC code on your 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

ING-CC-0170

J1823

Uplizna

ING-CC-0172

J3490, J3590, C9071

Viltepso

ING-CC-0173

J3490, J3590

Enspryng

ING-CC-0174

J3490, J3590, C9399

Kesimpta

ING-CC-0168

J9999, C9073

Tecartus

ING-CC-0171

J9223

Zepzelca

ING-CC-0169

J9316

Phesgo

ING-CC-0175

J9015

Proleukin

ING-CC-0176

J9032

Beleodaq

ING-CC-0178

J9262

Synribo

ING-CC-0177

J3304

Zilretta

ING-CC-0002

Q5122

Nyvepria

ING-CC-0038

J3110

Forteo

ING-CC-0179

J9999, C9069

Blenrep

ING-CC-0180

J3490, J3590, J9999, C9070

Monjuvi

ING-CC-0181

J3490

Veklury

If you have questions about this communication or need further assistance, please contact your local Provider Relations representative.

ACA-NU-0330-21


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June 2021 Anthem Blue Cross Provider News - California