Maine
Provider Communications
Specialty pharmacy prior authorization list expanded
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new clinical criteria or current clinical guideline will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Clinical Criteria/Guideline |
HCPCS or CPT Code |
NDC Code |
Drug |
CG-DRUG-63 |
J3490 |
68152-0112-01 68152-0114-01 |
Khapzory™ |
ING-CC-0002 |
Q5110 |
00069-0291-01 00069-0291-10 00069-0292-01 00069-0292-10 |
Nivestym™ |
ING-CC-0002 |
J3490 |
68152-0112-01 68152-0114-01 |
Udenyca™ |
ING-CC-0003 |
J1599 |
68982-0820-01 68982-0820-02 68982-0820-03 68982-0820-04 68982-0820-05 68982-0820-06 68982-0820-81 68982-0820-82 68982-0820-83 68982-0820-84 68982-0820-85 68982-0820-86 |
Panzyga® |
ING-CC-0034 |
J3590 |
47783-0644-01 |
Takhzyro® |
ING-CC-0062 |
J3590 |
61314-0871-02 61314-0871-06 61314-0876-02 |
Hyrimoz™ |
ING-CC-0062 |
Q5109 |
00069-0811-01 |
Ixifi™ |
ING-CC-0065 |
J7192 |
00026-3942-25 00026-3944-25 00026-3946-25 00026-3948-25 00026-4942-01 00026-4944-01 00026-4946-01 00026-4948-01 |
Jivi® |
ING-CC-0074 |
J8655 |
69639-0102-01 |
Akynzeo® |
ING-CC-0077 |
C9399 J3590 |
68135-0058-90 68135-0673-40 68135-0673-45 68135-0756-20 |
Palynziq™ |
ING-CC-0081 |
J0584 |
69794-0102-01 69794-0203-01 69794-0304-01 |
Crysvita® |
ING-CC-0082 |
C9399 J3490 |
71336-1000-01 |
Onpattro™ |
To access the clinical criteria information please click here.
Featured In:
February 2019 Anthem Maine Provider Newsletter