Effective November 1, 2018, prior authorization (PA) requirements will change for Part B injectable/infusible drugs Retacrit (epoetin alfa-epbx), Damoctocog and Ilumya (tildrakizumab) to be covered by Anthem Blue Cross for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

  • Retacrit (epoetin alfa-epbx) — for the treatment of anemia due to chronic kidney disease in patients on dialysis and not on dialysis, the effects of concomitant myelosuppressive chemotherapy or use of zidovudine in patients with HIV infection; also approved for the reduction of allogenic red blood cell transfusions in patients undergoing elective, noncardiac, nonvascular surgery (J3490, J3590)
  • Damoctocog alpha pegol — for treatment of Hemophilia A (J3490, J3590)
  • Ilumya (tildrakizumab-asmn) — for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy (J3490, J3590)

 

Please note, one or more of the drugs noted above are currently billed under the not otherwise classified (NOC) HCPCS J-codes J3490, J3590. Since these codes include all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS codes.

 

To request PA, you may use one of the following methods:

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call our Customer Care Center at 1-855-817-5786 for PA requirements.



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October 2018 Anthem Blue Cross Provider Newsletter - California