Georgia
Provider Communications
Anthem expands specialty pharmacy prior authorization list
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
The following clinical criteria or guideline will be effective September 1, 2019.
Clinical Criteria/Guideline |
HCPCS or CPT Code(s) |
NDC Code(s) |
Drug |
CG-DRUG-98 |
C9042 J9999 |
42367-0520-25 |
Belrapzo™ |
ING-CC-0088 |
C9399 J9999 |
72187-0401-01 |
Elzonris™ |
ING-CC-0087 |
C9399 J3590 |
72171-0501-01 72171-0505-01 |
Gamifant® |
ING-CC-0041 |
C9399 J3590 |
25682-0022-01 |
Ultomiris™ |
ING-CC-0086 |
J3490 |
50458-0028-00 50458-0028-02 50458-0028-03 |
Spravato™ |
Featured In:
Anthem June 2019 Provider News - Georgia