Prior authorization updates for specialty pharmacy -- April

Effective for dates of service on and after April 1, 2021, the following medical injectable codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of the 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 specific clinical criteria.

 

Clinical Criteria	HCPCS or CPT® code(s)	Drug
ING-CC-0164	J9281	Jelmyto (mitomycin)
ING-CC-0165	J9317	Trodelvy (sacituzumab Govitecan-hziy)
ING-CC-0061	J1950	Fensolvi (leuprolide acetate)

 

 

ANV-NU-0197-20