Pre-service clinical review drug list changes effective November 1, 2018

Effective for dates of service on or after November 1, 2018, the following specialty pharmacy codes from new or current medical policies and/or clinical UM guidelines will be added to our existing pre-service review process. 

 

Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM®), a separate company administering the program on behalf of Anthem, as applicable.

 

Clinical UM Guideline or Medical Policy	Drug Name	Drug Code(s)
DRUG.00098	Lutathera®	C9031, A9699, J9999
DRUG.00111	IlumyaTM	J3590
CG-DRUG-05	Retacrit®	Q5105, Q5106
CG-DRUG-16	FulphilaTM	J3590