Effective for dates of service on and after November 1, 2021, the following specialty drug codes from current or new clinical criteria documents will require prior authorization.

 

Please note, inclusion of national drug code (NDC) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

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

 

Clinical Criteria

HCPCS/CPT® code(s)

Drug

Drug class

ING-CC-0002

Q5122

Nyvepria

Blood cell deficiency

ING-CC-0038

J3110

Forteo

Osteoporosis

ING-CC-0168

J9999

C9073

Tecartus

CAR-T

ING-CC-0169

J9316

Phesgo

Cancer

ING-CC-0170

J1823

Uplizna

Immunosuppressive agents

ING-CC-0171

J9223

Zepzelca

Cancer

ING-CC-0172

J3490

J3590

C9071

Viltepso

Muscular dystrophies

ING-CC-0173

J3490

J3590

Enspryng

MISC conditions

ING-CC-0174

J3490

J3590

C9399

Kesimpta

Multiple sclerosis

ING-CC-0175

J9015

Proleukin

Cancer

ING-CC-0176

J9032

Beleodaq

Cancer

ING-CC-0177

J3304

Zilretta

Osteoarthritis

ING-CC-0178

J9262

Synribo

Cancer

ING-CC-0179

J9037

Blenrep

 

Generic:

Belantamab

Oncology

ING-CC-0180

J9349

Monjuvi

 

Generic: Tafasitamab-cxix

Oncology

ING-CC-0181

J3490

Veklury

 

Generic: Remdesivir

COVID-19

 

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

855-558-1443.

 

AWI-NU-0311-21/AWIPEC-1509-21

AWI-NU-0313-21/AWIPEC-1528-21



Featured In:
October 2021 Anthem Provider News - Wisconsin