Medicaid

 

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

 

 

ANV-NU-0270-21



Featured In:
October 2021 Anthem Provider News - Nevada