Specialty pharmacy updates - May 2022

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.

 

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

 

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.

 

Prior authorization updates

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

 

Access our clinical criteria to view the complete information for these prior authorization updates.

 

Clinical Criteria	Drug	HCPCS or CPT Code(s)
ING-CC-0062	Yusimry (adalimumab-aqvh)	J3590
ING-CC-0072	Vabysmo (faricimab-svoa)	J3490, J3590
ING-CC-0210	Enjaymo (sutimlimab-jome)	C9399, J3490, J3590, J9999
ING-CC-0211*	Kimmtrak (tebentafusp-tebn)	C9399, J3490, J3590, J9999
ING-CC-0212	Tezspire (tezepelumab-ekko)	C9399, J3590
ING-CC-0213	Voxzogo (vosoritide)	C9399, J3490

*Oncology use is managed by AIM.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Step therapy updates

Effective for dates of service on and after August 1, 2022, 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. 

 

Access our clinical criteria to view the complete information for these step therapy updates.

 

Clinical Criteria	Status	Drug	HCPCS or CPT Code(s)
ING-CC-0072	Non-Preferred	Vabysmo (faricimab-svoa)	J3490, J3590

 

Quantity limit updates

Effective for dates of service on and after August 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-0062	Hulio (adalimumab-fkjp)	J3590
ING-CC-0062	Ixifi (infliximab-qbtx)	Q5109
ING-CC-0062	Yusimry (adalimumab-aqvh)	J3590
ING-CC-0072	Vabysmo (faricimab-svoa)	J3490, J3590
ING-CC-0210	Enjaymo (sutimlimab-jome)	C9399, J3490, J3590, J9999
ING-CC-0212	Tezspire (tezepelumab-ekko)	C9399, J3590
ING-CC-0213	Voxzogo (vosoritide)	C9399, J3490

 

2152-0522-PN-CTNH