Effective for dates of service on and after September 1, 2019, the following specialty pharmacy codes from new or current clinical criteria or guideline will be included in our pre-service clinical review process.

Please note, inclusion of NDC code on your claim will help expedite the claim processing of drugs billed with a not otherwise classified (NOC) code.

The following clinical criteria or guideline will be effective September 1, 2019.

Clinical Criteria/Guideline

HCPCS or CPT Code(s)

NDC Code(s)

Drug

CG-DRUG-98

C9042, J9999

42367-0520-25

Belrapzo™

ING-CC-0088

C9399, J9999

72187-0401-01

Elzonris™

ING-CC-0087

C9399, J3590

72171-0501-01

72171-0505-01

Gamifant®

ING-CC-0041

C9399, J3590

25682-0022-01

Ultomiris™

ING-CC-0086

J3490

50458-0028-00

50458-0028-02

50458-0028-03

Spravato™

 



Featured In:
June 2019 Anthem New Hampshire Provider Newsletter