Policy Updates Prior AuthorizationMedicaidDecember 18, 2023

Prior Authorization update - Lamzede, Lunsumio, Rebyota, etc.

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on and after February 1, 2024, 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 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-0230

J9029

Adstiladrin (nadofaragene firadenovec-vncg)

CC-0231

C9399, J3490

Lamzede (velmanase alfa-tycv)

CC-0232

J9350

Lunsumio (mosunetuzumab-axgb)

CC-0233

J1440

Rebyota (fecal microbiota, live – jslm)

CC-0235

C9399, J3590

Revcovi (elapegademase-lvlr)

CC-0236

J2502

Signifor LAR (pasireotide)

CC-0234

J2781

Syfovre (pegcetacoplan)

CC-0116

J9056

Vivimusta (bendamustine)

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-037043-23-CPN36783

PUBLICATIONS: January 2024 Provider Newsletter