Medicaid

 

Effective for dates of service on and after January 1, 2022 the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

 

Please note, the inclusion of a national drug code on your medical claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

 

Clinical Criteria

HCPCS or CPT® code(s)

Drug

ING-CC-0183

J3590

Sogroya

ING-CC-0184

J9348

Danyelza

ING-CC-0185

J0224

Oxlumo

ING-CC-0186

J9353

Margenza

ING-CC-0187

J3490, J3590,  Q2054

Breyanzi

ING-CC-0189

J3490, J3590, J1426

Amondys 45

ING-CC-0190

J3490, J3590, C9399

Nulibry

 

 

If you have questions about this communication, call Provider Services at 844-396-2330.

 


ANVPEC-1802-21

ANVPEC-1775-21



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December 2021 Anthem Provider News - Nevada