CurrentAnthemPolicy N/A

Prior authorization requirements for Part B drugs: Zevalin (ibritumomab tiuxetan) and Eptacog (recombinant factor VIIa)

This document notifies providers of new prior authorization requirements for two Medicare Part B injectable/infusible drugs (Zevalin and Eptacog) covered by Anthem and explains access to detailed PA requirements for contracted providers.

Policy Summary

PayerAnthem

PolicyPrior authorization requirements for Part B drugs: Zevalin and Eptacog

Policy CodePolicy N/A

Change TypeAdded prior authorization requirements

Effective DateAug 1, 2018

Next Review DateN/A

Key ActionObtain prior authorization via Availity or Provider Services before billing for Zevalin or Eptacog.

SourceLink

POLICY UPDATE CHANGES

Prior authorization requirements will be added for Zevalin (ibritumomab tiuxetan).

Prior authorization requirements will be added for Eptacog (recombinant factor VIIa) billed under NOC HCPCS codes (J3490, J3590).

2Part B drugs newly subject to PA

2018-08-01PA effective date

J9999; J3490; J3590HCPCS codes referenced

Coverage criteria and policy scope

Drugs requiring prior authorization

Prior authorization required for the following drugs

Eptacog coverage context: Eptacog beta (recombinant factor VIIa) is subject to prior authorization when used for treatment of hemophilia A and B in patients who have developed inhibitors (antibodies) to factor VIII or IX.

Billed under NOC HCPCS codes J3490/J3590; detailed PA criteria available via Availity

Federal and state law, state contract language, and CMS guidelines — including definitions and any specific contract provisions or exclusions — take precedence over these precertification rules and must be considered first when determining coverage for Part B drugs. The notification adds prior authorization requirements for Zevalin (ibritumomab tiuxetan) and Eptacog (recombinant factor VIIa) effective 2018-08-01, and providers should follow applicable contract terms and CMS guidance when applying these new PA requirements.

Operational note: when a prior authorization request for a drug billed under a Not Otherwise Classified (NOC) HCPCS code (for example, J3490 or J3590) is denied for medical necessity, the plan’s denial applies to the drug itself rather than to the NOC HCPCS code. This distinction should be used in claim edits and denial processing.

HCPCS and billing codes

Policy Summary

PayerAnthem

PolicyPrior authorization requirements for Part B drugs: Zevalin and Eptacog

Policy CodePolicy N/A

Change TypeAdded prior authorization requirements

Effective DateAug 1, 2018

Next Review DateN/A

Key ActionObtain prior authorization via Availity or Provider Services before billing for Zevalin or Eptacog.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered HCPCS CodesHCPCSCovered

J9999

Zevalin (ibritumomab tiuxetan) referenced

NOC HCPCS Codes (currently used)HCPCS

J3490	Not Otherwise Classified (NOC) — used for Eptacog beta (recombinant factor VIIa)
J3590	Not Otherwise Classified (NOC) — used for Eptacog beta (recombinant factor VIIa)

Coding summary

Covered HCPCS (explicit)J9999 — Zevalin (ibritumomab tiuxetan)

NOC HCPCS (currently used)J3490, J3590 — used for Eptacog beta (recombinant factor VIIa)

Effective date2018-08-01 — PA requirements added for listed Part B drugs

PA accessDetailed prior authorization requirements available via Availity Provider Self-Service Tool or Provider Services phone number on member ID card

NOC HCPCS (Not Otherwise Classified) definition

DefinitionNot Otherwise Classified (NOC) HCPCS codes are unlisted J‑codes used when no specific J‑code exists for a drug (examples: J3490, J3590).

Usage exampleEptacog beta (recombinant factor VIIa) is currently billed under NOC codes J3490 and J3590 because no specific J‑code had been established at the time of this notice.

Denial implicationIf authorization for a drug billed under an NOC code is denied for medical necessity, the plan's denial will be for the drug rather than the HCPCS code.

What providers must do

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain Part B injectable/infusible drugs. Zevalin (ibritumomab tiuxetan) and Eptacog (recombinant factor VIIa) are subject to Anthem prior authorization effective 2018-08-01. Contracted providers must obtain PA before delivering these drugs.

Zevalin (ibritumomab tiuxetan) — treatment of relapsed or refractory low‑grade or follicular B‑cell non‑Hodgkin's lymphoma (NHL) or previously untreated follicular NHL. (J9999)
Eptacog beta (recombinant factor VIIa) — treatment for hemophilia A and B patients with inhibitors to factor VIII or IX. Currently billed under NOC HCPCS codes J3490 and J3590 (no specific J‑code established).

Denial Risk

Denial Risk for Non‑Compliance

Failure to obtain the required prior authorization or failure to meet the PA requirements may result in denial of the claim. This includes services billed under Not Otherwise Classified (NOC) codes (e.g., J3490, J3590) — a denied authorization for medical necessity will result in the plan denying the drug/service regardless of the specific NOC billing code used.

Note

How to Obtain PA Requirements

Contracted providers should access detailed prior authorization requirements and submission instructions via Availity (Provider Self‑Service). If you are unable to access Availity or are a non‑contracted provider, call Provider Services at the number on the member's ID card for authorization requirements and assistance.

Availity Provider Self‑Service: www.availity.com — detailed PA criteria and submission steps
Provider Services: call the number on the member's ID card if you cannot access Availity or are non‑contracted

Documentation Required

Additional Provider Actions

Other provider actions: ensure documentation supports medical necessity per the PA criteria at time of submission and include correct HCPCS codes (use J9999 for Zevalin where applicable; Eptacog may be billed under J3490/J3590 until a specific J‑code is established). Verify member eligibility and benefits prior to service and retain authorization details for claim submission.

Include supporting clinical documentation with PA and claims to demonstrate indication and prior treatment history.
Verify eligibility and benefits and reference the authorization number on claims.
For Eptacog billed under NOC codes, document the drug name and clinical rationale clearly in the medical record and on the claim as required.

OpenPayer

Prior authorization requirements for Part B drugs: Zevalin (ibritumomab tiuxetan) and Eptacog (recombinant factor VIIa)

Coverage criteria and policy scope

HCPCS and billing codes

What providers must do

Initial therapy prior authorization criteria

Applicable site-of-care guidance

Background and clinical context