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, the inclusion of a National Drug Code (NDC) on the 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	Drug name
CC‑0065	J7204	Esperoct (factor viii recombinant, glycopegylated)

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 contact Provider Services at 800-450-8753.

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