Products & Programs PharmacyMedicaid Managed CareApril 16, 2024

Prior authorization updates for medications billed under the medical benefit

Effective June 1, 2024, the following medication codes will require prior authorization.

Please note, 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-0244

J9286

Columvi (glofitamab-gxbm)

CC-0245

C9162

Izervay (avacincaptad pegol)

CC-0246

J9333

Rystiggo (rozanolixizumab-noli)

CC-0207

J9334

Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)

CC-0072

C9161

Eylea HD (aflibercept high dose)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relations representative or call Provider Services at 844-912-1226.

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

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-050813-24-CPN50561

PUBLICATIONS: May 2024 Provider Newsletter