Policy Updates Prior AuthorizationMedicaidJanuary 30, 2024

Cimerli medical prior authorization update

Effective for dates of service on and after March 1, 2024, the following medication codes from current or new Clinical Criteria documents billed on medical claims 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

Q5128

Cimerli (ranibizumab-cqrn)

What if I need assistance:

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 855-661-2028.

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

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

KYBCBS-CD-020180-23-CPN19824

PUBLICATIONS: March 2024 Provider Newsletter