Products & Programs PharmacyMedicaidJune 18, 2024

Prior authorization updates for medications billed under the medical benefit

Effective August 1, 2024, the following medication codes will require prior authorization.

Please note, inclusion of a National Drug Code (NDC) 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-0252

C9399

Adzynma (ADAMTS13, recombinant-krhn)

CC-0253

J3490, J3590, J9999

Aphexda (motixafortide)

CC-0107

J3490, J3590

Avzivi (bevacizumab-tnjn)

CC-0042

J3490

Bimzelx (bimekizumab-bkzx)

CC-0032

C9160

Daxxify (daxibotulinumtoxinA-lanm)

CC-0059

J3490

Focinvez (fosaprepitant)

CC-0255

C9399, J3490, J3590

Loqtorzi (toripalimab-tpzi)

CC-0050

J3590

Omvoh (mirikizumab-mrkz)

CC-0256

J3490

Rivfloza (nedosiran)

CC-0002

J3490, J3590

Ryzneuta (efbemalenograstim alfa-vuxw)

CC-0066

J3490, J3590

Tofidence (tocilizumab-bavi)

CC-0257

C9399, J3490

Wainua (eplontersen)

CC-0254

J3490

Zilbrysq (zilucoplan)

CC-0062

J3590

Zymfentra (infliximab-dyyb)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your 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.

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CD-056682-24-CPN56332

PUBLICATIONS: July 2024 Provider Newsletter