Prior authorization requirements for Part B drug Nivestym

Effective January 1, 2019, prior authorization (PA) requirements will change for Part B injectable/infusible drug Nivestym (filgrastim-aafi) 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:

• Nivestym (filgrastim-aafi) — for treatment of febrile neutropenia, hematopoietic syndrome of acute radiation syndrome, mobilization of autologous peripheral blood progenitor cells (PBPCs) into the peripheral blood, and severe chronic neutropenia (J3590)

 

Please note, the drug noted above is currently billed under the not otherwise classified (NOC) HCPCS J-code J3590. Since this code includes 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 code.

 

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

• Web: https://www.availity.com
• Fax: 1-866-959-1537
• Phone: 1-855-817-5786

 

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 us at 1-855-917-5786 for PA requirements.