Products & Programs PharmacyHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingOctober 5, 2023

Notice of Material Amendment to Healthcare Contract: Medicaid Prior Authorization Provider Notice Vegzelma

Prior authorization updates for medications billed under the medical benefit

Effective December 1, 2023, the following medication codes will require prior authorization.

Please note, inclusion of a national drug code 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-0072

Q5129

Vegzelma (bevacizumab-adcd)

CC-0107

Q5129

Vegzelma (bevacizumab-adcd)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Network Relations consultant. You can also contact a representative through CHAT in Availity Essentials via Payer Spaces or call Provider Services at one of the phone numbers listed below:

  • 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-026965-23-CPN25795

PUBLICATIONS: November 2023 Provider Newsletter