Effective for dates of service on and after December 1, 2022, 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 claim processing.


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


Clinical Criteria

HCPCS or CPT® code(s)

Drug name


J3490, J3590, C9086

Saphnelo (anifrolumab-fnia)


J3490, J3590

Ryplazim (plasminogen, human-tvmh)


What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 844-396-2330.


Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.



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October 2022 Anthem Provider News - Nevada