Policy Updates Prior AuthorizationMedicaidMay 23, 2023

Prior Authorization Update for Briumvi, Elahere, Imjudo, Leqembi, Pedmark, Sunlenca, Tecvayli, Tzield

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on and after September 1, 2023, the following medication codes billed on medical claims will require prior authorization in accordance with the requirements of the current or new Clinical Criteria documents.

Please note, inclusion of a national drug code on your medical claim is necessary for claims processing.

Visit the ClinicalCriteria website to search for the specific Clinical Criteria listed below.

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

CC-0227

J3490, J3590

Briumvi (ublituximab)

CC-0226

J3590, J9999

Elahere (mirvetuximab)

CC-0223

J3490, J3590, J9999

Imjudo (tremelimumab-actl)

CC-0228

J3490, J3590

Leqembi (lecanemab)

CC-0224

J3490, J9999

Pedmark (sodium thiosulfate injection)

CC-0229

J3490, C9399

Sunlenca (lenacapavir)

CC-0222

J3490, J3590, J9999

Tecvayli (teclistamab-cqyv)

CC-0225

J3490, J3590

Tzield (teplizumab-mzwv)

















What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Relationship Management associate or call Provider Services at the following numbers:

Medi-Cal Customer Care Centers at 800-407-4627 (outside L.A. County) or 888-285-7801 (inside L.A. County).

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

CABC-CD-023588-23-CPN23286

PUBLICATIONS: June 2023 Provider Newsletter