Products & Programs PharmacyMedicaid Managed CareMarch 6, 2024

Prior authorization updates for medications billed under the medical benefit

Effective May 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-0241

J3490, J3590

Elfabrio (pegunigalsidase alfa-iwxj)

CC-0242

C9399, J3490, J3590, J9999

Epkinly (epcoritamab-bysp)

CC-0237

J3490, J3590

Qalsody (tofersen)

CC-0243

J3490, J3590

Vyjuvek (beremagene geperpavec)

CC-0240

J9999

Zynyz (retifanlimab-dlwr)








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 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-047749-23-CPN47364

PUBLICATIONS: April 2024 Provider Newsletter