Prior authorization updates for specialty pharmacy effective August 2021

Prior authorization updates

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

 

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

 

Visit our website to access the clinical criteria information.  

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
**ING-CC-0186	J3490, J3590, J9999	Margenza
*ING-CC-0187	J3490, J3590, J9999	Breyanzi
*ING-CC-0188	J3490, J3590	Imcivree
*ING-CC-0189	J3490, J3590, C9399	Amondys 45
*ING-CC-0190	J3490, J3590, C9399	Nulibry
**ING-CC-0094	J9304	Pemfexy
**ING-CC-0075	J3590, J9999, C9399	Riabni

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

**Oncology use is managed by AIM.

 

Prior authorization coding update – change in clinical criteria

Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.

 

Quantity limit updates

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

 

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

 

Visit our website to access the clinical criteria information.  

 

Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company, and are shown in italics below.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0189	J3490, J3590, C9399	Amondys 45
*ING-CC-0190	J3490, J3590, C9399	Nulibry

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

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