CurrentAnthemPolicy N/A

Medical Benefit Precertification List

A list of medical-benefit drugs for which precertification (preauthorization) is required for commercial plan members under Anthem's Medical Benefit Drug Review program. The document enumerates drugs and associated HCPCS/CPT/Q-codes but contains no clinical criteria within this file.

Policy Summary

PayerAnthem

PolicyMedical Benefit Precertification List

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrecertification (preauthorization) is required for commercial plan members for all medical benefit drugs listed in this document; providers must obtain precertification through Anthem's Medical Benefit Drug Review program prior to administration/billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

~700Drugs listed

commercialApplies to

precertificationRequirement

Policy overview

This is an Anthem administrative list of medical-benefit drugs that require precertification under Anthem's Medical Benefit Drug Review program for commercial plan members. The document enumerates drugs and associated HCPCS/CPT/Q-codes for which precertification is required.

Precertification requirement

For commercial plan members using the Medical Benefit Drug Review program:

Precertification is required for the medical benefit drugs listed in this document.

Providers must obtain precertification through Anthem's Medical Benefit Drug Review program prior to administration or billing for any medical-benefit drug on this list; do not proceed with administration or claim submission for listed drugs without completing Anthem's precertification process.

Code list — medical benefit drugs requiring precertification

Precertification required - listed medical benefit drugsHCPCSCovered

Q5145	Abrilada
J3262	Actemra (IV)
J3590	Actemra (SC) / many other products (unspecified biologic/billed-as-J3590)
C9399	Actemra (SC) / many other products (unspecified infusion code)
J0801	Acthar
J0791	Adakveo
C9399	Adbry (also J3590 listed)
J3590	Adbry (also C9399 listed)
J0172	Aduhelm
J7192	Advate

1–10 of 206

1/21

Required provider actions

Prior Authorization

Precertification required

Precertification (preauthorization) is required for commercial plan members for all medical benefit drugs listed in this document; providers must obtain precertification through Anthem's Medical Benefit Drug Review program prior to administration/billing.

Applies to: Commercial plan members
Obtain precertification via: Anthem's Medical Benefit Drug Review program