Policy Updates Prior AuthorizationMedicaidMay 31, 2023

Prior Authorization Update for Briumvi, Elahere, Imjudo, Leqembi, Pedmark, Sunlenca, Tecvayli, Tzield

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 June 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

CC-0227

J3490, J3590

Briumvi (ublituximab)

CC-0226

J3590, J9999

Elahere (mirvetuximab)

CC-0223

J3490, J3590, J9999

Imjudo (tremelimumab-actl)

CC-0228

J3490, J3590

Leqembi (lecanemab)

CC-0224

J3490, J9999

Pedmark (sodium thiosulfate injection)

CC-0229

J3490, C9399

Sunlenca (lenacapavir)

CC-0222

J3490, J3590, J9999

Tecvayli (teclistamab-cqyv)

CC-0225

J3490, J3590

Tzield (teplizumab-mzwv)
















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-023284-23

PUBLICATIONS: June 2023 Provider Newsletter