Prior authorization updates for medications billed under the medical benefit

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