Prior authorization updates for specialty pharmacy effective July 1, 2021

Prior authorization 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 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 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).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0027	J0897	Xgeva

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

Quantity limit 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 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 use of 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).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0027	J0897	Xgeva

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

1090-0421-PN-NE