Products & Programs PharmacyMedicaidFebruary 3, 2025

Prior authorization updates for medications billed under the medical benefit

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

Please note, inclusion of a National Drug Code (NDC) on the medical claim is necessary for claims processing.

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

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

CC‑0264

C9399, J9999

Anktiva (nogapendekin alfa inbekicept‑pmln)

CC‑0166

J3590

Hercessi (trastuzumab‑strf)

CC‑0263

C9399, J9999

Imdelltra (tarlatamab‑dlle)

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.

CABC-CD-072548-24-CPN72388

PUBLICATIONS: March 2025 Provider Newsletter