Products & Programs PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMay 6, 2024

Prior authorization updates for medications billed under the medical benefit

Effective July 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-0248

C9165, J3490, J3590, J9999

Elrexfio (elranatamab-bcmm)

CC-0068

C9399, J3590

Ngenla (somatrogon-ghla)

CC-0018

J3490, J3590

Pombiliti (cipaglucosidase alfa-atga)

CC-0249

C9163, J3490, J3590, J9999

Talvey (talquetamab-tgvs)

CC-0020

J3490, J3590

Tyruko (natalizumab-sztn)

CC-0250

C9399, J3590

Veopoz (pozelimab-bbfg)

CC-0251

C9164, J3490

Ycanth (cantharidin)

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 800-901-0020.

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

HealthKeepers, Inc. is an independent licensee of the Blue Cross Blue Shield Association. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

VABCBS-CD-050828-24-CPN50562

PUBLICATIONS: June 2024 Provider Newsletter