Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on or after April 1, 2025, the following medication codes will require preapproval.

Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing.

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

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

Clinical Criteria	HCPCS or CPT® code(s)	Drug name
CC‑0264	C9399, J9999	Anktiva (nogapendekin alfa inbekicept‑pmln)
CC‑0166	J3590	Hercessi (trastuzumab‑strf)
CC‑0263	C9399, J9999	Imdelltra (tarlatamab‑dlle)

What if I need assistance?

If you have any 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.