Prior authorization updates for medications billed under the medical benefit

Medicaid

 

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
ING-CC-0202	J3490, J3590, C9086	Saphnelo (anifrolumab-fnia)
ING-CC-0203	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.

 

NVBCBS-CD-005258-22-CPN5089