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 is necessary for claim processing.


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


Clinical Criteria

HCPCS or CPT® code(s)

Drug name


J3490, J3590

BESREMi ( (ropeginterferon alfa-2b-njft)



Vyvgart (efgartigimod alfa-fcab)



Adbry (tralokinumab)



Leqvio (inclisiran)


What if I need assistance?

If you have questions about this communication or need assistance with any other item, use the online chat on the Availity* Portal, contact your local Provider Experience representative, or call Provider Services at:

  • Hoosier Healthwise: 866-408-6132
  • Healthy Indiana Plan: 844-533-1995
  • Hoosier Care Connect: 844-284-1798


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


INBCBS-CD-004159-22 (INBCBS-CAID-001066-22)


Featured In:
September 2022 Anthem Provider News - Indiana