Products & Programs PharmacyMedicaidJanuary 7, 2025

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on or after May 1, 2025, the following medication codes will require prior authorization.

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

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

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

CC‑0265

J0175

Kisunla (donanemab)

CC‑0041

J3590

Piasky (crovalimab‑akkz)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 800‑407-4627 (TTY 711) outside L.A. County or 888‑285-7801 (TTY 711) inside L.A. County.

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

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

ABC-CD-072630-24-CPN72396

PUBLICATIONS: February 2025 Provider Newsletter