Policy Updates Prior AuthorizationMedicaidJune 26, 2023

Medical Prior Authorization update Fylnetra, Rolvedon, and Stimufend

Prior authorization updates for medications billed under the medical benefit

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Effective for dates of service on and after August 1, 2023, 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 claims 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-0002

Q5130

Fylnetra (pegfilgrastim-pbbk)

ING-CC-0002

J1449

Rolvedon (eflapegrastim-xnst)

ING-CC-0002

Q5127

Stimufend (pegfilgrastim-fpgk)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at 800-450-8753.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

NYBCBS-CD-020381-23-CPN19823

PUBLICATIONS: July 2023 Provider Newsletter