Specialty pharmacy updates for Anthem are listed below.

 

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), a separate company.

 

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

 

Site of care updates

 

Effective for dates of service on and after January 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.

 

Access our Clinical Criteria to view the complete information for these site of care updates.

 

Clinical Criteria

HCPCS or CPT Code

Drug

*ING-CC-0062

Q5121

Avsola

*ING-CC-0081

J0584

Crysvita

*ING-CC-0162

J3241

Tepezza

* Non-oncology use is managed by the medical specialty drug review team.

 

Quantity limit updates

 

Effective for dates of service on and after January 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Access our Clinical Criteria to view the complete information for these quantity limit updates.

 

 

Clinical Criteria

Drug

HCPCS or CPT Code(s)

ING-CC-0009

Lemtrada

J0202

ING-CC-0011

Ocrevus

J2350

ING-CC-0014

Avonex

J1826

Q3027

Betaseron

J1830

Copaxone

J1595

Extavia

J1830

Glatopa

J1595

Plegridy

J3590

C9399

Rebif

J1826

Q3028

ING-CC-0020

Tysabri

J2323

ING-CC-0029

Dupixent

J3490

J3590

ING-CC-0038

Bonsity

J3110

Forteo

J3110

Tymlos

C9399

J3490

ING-CC-0042

Siliq

C9399

J3490

J3590

Taltz

C9399

J3490

J3590

ING-CC-0048

Spinraza

J2326

ING-CC-0062

Avsola

Q5121

Erelzi

J3590

Eticovo

J3590

ING-CC-0066

Kevzara

C9399

J3590

J3490

ING-CC-0075

Riabni

Q5123

ING-CC-0077

Palynziq

C9399

J3590

ING-CC-0082

Onpattro

J0222

ING-CC-0156

Reblozyl

J0896

ING-CC-0159

Scenesse

J7352

ING-CC-0160

Vyepti

J3032

ING-CC-0162

Tepezza

J3241

ING-CC-0163

Durysta

J7351

ING-CC-0170

Uplizna

J1823

ING-CC-0172

Viltepso

J1427

ING-CC-0173

Enspryng

J3490

J3590

ING-CC-0174

Kesimpta

C9399

J3490

J3590

ING-CC-0177

Zilretta

J3304

ING-CC-0181

Veklury

J3490

ING-CC-0183

Sogroya

J3590

ING-CC-0185

Oxlumo

J0224

ING-CC-0188

Imcivree

J3490

J3590

ING-CC-0193

Evkeeza

J3490

C9079

ING-CC-0194

Cabenuva

J3490

C9077


1338-1021-PN-NE



Featured In:
October 2021 Anthem Connecticut Provider News