Effective for dates of service on and after September 1, 2019, the following specialty pharmacy codes from new or current clinical criteria or guideline will be included in our prior authorization review process.

 

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

 

The following clinical criteria or guideline will be effective September 1, 2019.

 

Clinical Criteria/ Guideline


HCPCS or CPT Code(s)



NDC Code(s)



Drug

CG-DRUG-98

C9042

J9999

42367-0520-25

Belrapzo™

ING-CC-0088

C9399

J9999

72187-0401-01

Elzonris™

ING-CC-0087

C9399

J3590

72171-0501-01

72171-0505-01

Gamifant®

ING-CC-0041

C9399

J3590

25682-0022-01

Ultomiris™

ING-CC-0086

J3490

50458-0028-00

50458-0028-02

50458-0028-03

Spravato™

 



Featured In:
June 2019 Anthem Provider Newsletter - Ohio