MedicaidOctober 1, 2021
Prior authorization updates for specialty pharmacy
Effective for dates of service on and after November 1, 2021, the following specialty drug codes from current or new clinical criteria documents will require prior authorization.
Please note, inclusion of national drug code (NDC) on your 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 |
Drug classification |
ING-CC-0170 |
J1823 |
Uplizna |
Immunosuppressive agents |
ING-CC-0172 |
J3490, J3590, C9071 |
Viltepso |
Muscular dystrophies |
ING-CC-0173 |
J3490, J3590 |
Enspryng |
MISC conditions |
ING-CC-0174 |
J3490, J3590, C9399 |
Kesimpta |
Multiple sclerosis |
ING-CC-0168 |
J9999, C9073 |
Tecartus |
CAR-T |
ING-CC-0171 |
J9223 |
Zepzelca |
Cancer |
ING-CC-0169 |
J9316 |
Phesgo |
Cancer |
ING-CC-0175 |
J9015 |
Proleukin |
Cancer |
ING-CC-0176 |
J9032 |
Beleodaq |
Cancer |
ING-CC-0178 |
J9262 |
Synribo |
Cancer |
ING-CC-0177 |
J3304 |
Zilretta |
Osteoarthritis |
ING-CC-0002 |
Q5122 |
Nyvepria |
Blood cell deficiency |
ING-CC-0038 |
J3110 |
Forteo |
Osteoporosis |
PUBLICATIONS: October 2021 Anthem Provider News - Nevada
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