Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on and after November 1, 2022, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of a national drug code on your medical 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 name
ING-CC-0205	J9331	Fyarro (sirolimus albumin bound)
ING-CC-0206	J3490, J3590	BESREMi (ropeginterferon alfa-2b-njft)
ING-CC-0207	J9332	Vyvgart (efgartigimod alfa-fcab)
ING-CC-0208	J3490	Adbry (tralokinumab)
ING-CC-0209	J3490	Leqvio (inclisiran)

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

 

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CABC-CD-004131-22