Products & Programs PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 19, 2025

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on or after April 1, 2025, the following medication codes will require preapproval.

Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing.

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

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

CC‑0264

C9399, J9999

Anktiva (nogapendekin alfa inbekicept‑pmln)

CC‑0166

J3590

Hercessi (trastuzumab‑strf)

CC‑0263

C9399, J9999

Imdelltra (tarlatamab‑dlle)

What if I need assistance?

If you have any questions about this communication or need assistance with any other item, contact your provider relationship management representative or call Provider Services at 800‑901-0020.

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.

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PUBLICATIONS: March 2025 Provider Newsletter