MedicaidSeptember 30, 2021
Prior authorization updates for specialty pharmacy IV
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
Please note, inclusion of national drug code (NDC) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Visit the Clinical Criteria website to search for the specific clinical criteria listed below.
Clinical Criteria |
HCPCS or CPT® code(s) |
Drug |
Drug classification |
ING-CC-0170 |
J1823 |
Uplizna |
Immunosuppressive agents |
ING-CC-0172 |
J3490, J3590, C9071 |
Viltepso |
Muscular dystrophies |
ING-CC-0173 |
J3490, J3590 |
Enspryng |
MISC conditions |
ING-CC-0174 |
J3490, J3590, C9399 |
Kesimpta |
Multiple sclerosis |
ING-CC-0168 |
J9999, C9073 |
Tecartus |
CAR-T |
ING-CC-0171 |
J9223 |
Zepzelca |
Cancer |
ING-CC-0169 |
J9316 |
Phesgo |
Cancer |
ING-CC-0175 |
J9015 |
Proleukin |
Cancer |
ING-CC-0176 |
J9032 |
Beleodaq |
Cancer |
ING-CC-0178 |
J9262 |
Synribo |
Cancer |
ING-CC-0177 |
J3304 |
Zilretta |
Osteoarthritis |
ING-CC-0002 |
Q5122 |
Nyvepria |
Blood cell deficiency |
ING-CC-0038 |
J3110 |
Forteo |
Osteoporosis |
PUBLICATIONS: October 2021 Newsletter
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