Prior authorization updates for specialty pharmacy

Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of NDC code on your 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
ING-CC-0170	J1823	Uplizna
ING-CC-0172	J3490, J3590, C9071	Viltepso
ING-CC-0173	J3490, J3590	Enspryng
ING-CC-0174	J3490, J3590, C9399	Kesimpta
ING-CC-0168	J9999, C9073	Tecartus
ING-CC-0171	J9223	Zepzelca
ING-CC-0169	J9316	Phesgo
ING-CC-0175	J9015	Proleukin
ING-CC-0176	J9032	Beleodaq
ING-CC-0178	J9262	Synribo
ING-CC-0177	J3304	Zilretta
ING-CC-0002	Q5122	Nyvepria
ING-CC-0038	J3110	Forteo
ING-CC-0179	J9999, C9069	Blenrep
ING-CC-0180	J3490, J3590, J9999, C9070	Monjuvi
ING-CC-0181	J3490	Veklury

If you have questions about this communication or need further assistance, please contact your local Provider Relations representative.

ACA-NU-0330-21