Products & Programs PharmacyMedicaidMarch 22, 2024

Prior authorization updates for medications billed under the medical benefit

Effective July 1, 2024, 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 website to search for the specific Clinical Criteria listed below.

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

CC-0248

C9165, J3490 J3590, J9999

Elrexfio (elranatamab-bcmm)

CC-0068

C9399, J3590

Ngenla (somatrogon-ghla)

CC-0018

J3490, J3590

Pombiliti (cipaglucosidase alfa-atga)

CC-0249

C9163, J3490, J3590, J9999

Talvey (talquetamab-tgvs)

CC-0020

J3490, J3590

Tyruko (natalizumab-sztn)

CC-0250

C9399, J3590

Veopoz (pozelimab-bbfg)

CC-0251

C9164, J3490

Ycanth (cantharidin)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at one of the following phone numbers:

  • Outside of Los Angeles County: 800-407-4627
  • Los Angeles County: 888-285-7801

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-051164-24-CPN50821

PUBLICATIONS: April 2024 Provider Newsletter