Policy Updates Prior AuthorizationMedicaidOctober 16, 2023

Medical Prior Authorization Update Fylnetra, Rolvedon, Stimufend

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on and after December 1, 2023, 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

ING-CC-0002

Q5130

Fylnetra (pegfilgrastim-pbbk)

ING-CC-0002

J1449

Rolvedon (eflapegrastim-xnst)

ING-CC-0002

Q5127

Stimufend (pegfilgrastim-fpgk)

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.

KYBCBS-CD-020379-23-CPN19823

PUBLICATIONS: November 2023 Provider Newsletter