Prior authorization updates

Effective for dates of service on and after September 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

**ING-CC-0191

J3490, J9999, C9399

Pepaxto

**ING-CC-0192

J3490, C9399

Cosela

*ING-CC-0193

J3490, C9399

Evkeeza

*ING-CC-0194

J3490

Cabenuva

*ING-CC-0167

J9999, J3590, C9399

Riabni

* Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team.

** Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Visit our website to access the clinical criteria information.  

 

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

 

Step therapy updates

Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process. In addition, please note that Inflectra is changing to preferred status effective July 1, 2021.

 

Clinical Criteria

Preferred Status

Drug

ING-CC-0062

Preferred

Inflectra

ING-CC-0062

Preferred

Remicade

ING-CC-0062

Non-preferred

Avsola

ING-CC-0062

Non-preferred

Renflexis

 

Prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications is managed by AIM.

 

Visit our website to access the clinical criteria information.  

 

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

 

1184-0621-PN-NE

 



Featured In:
June 2021 Anthem Connecticut Provider News