Prior authorization updates for specialty pharmacy effective September 1, 2020

Effective for dates of service on and after September 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our pre-service review process.

Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code. To access the clinical criteria document information please click here.  

 

Prior authorization 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 in italics.

Clinical Criteria	HCPCS Code	Drug
ING-CC-0161	C9399	Sarclisa
ING-CC-0161	J3490	Sarclisa
ING-CC-0161	J3590	Sarclisa
ING-CC-0161	J9999	Sarclisa
*ING-CC-0058	J2354	Bynfezia

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

 

Step therapy updates

Effective for dates of service on and after September 1, 2020, 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.

 

To access the step therapy drug list, please click here.

 

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

Clinical Criteria	Status	Drug(s)	HCPCS Code
ING-CC-0003	Non-preferred	Panzyga	J1599
ING-CC-0003	Non-preferred	Xembify	J3490

 

458-0620-PN-NE