Products & Programs PharmacyMedicaidSeptember 9, 2024

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on or after November 1, 2024, the following medication codes will require prior authorization.

Please note that the 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-0003

J1599

Alyglo (immune globulin intravenous,
human-stwk)

CC-0062

J3590

Simlandi (adalimumab-ryvk)

CC-0261

C9399, J3590

Winrevair (sotatercept-csrk)

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.

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-065389-24-CPN64077

PUBLICATIONS: October 2024 Provider Newsletter