Effective for dates of service on and after September 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.

 

To access the Clinical Criteria information, click here.

 

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-0191

J3490, J9999, C9399

Pepaxto

**ING-CC-0192

J3490, C9399

Cosela

*ING-CC-0193

J3490, C9399

Evkeeza

*ING-CC-0194

J3490

Cabenuva

*ING-CC-0167

J9999, J3590, C9399

Riabni


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

** Oncology use is managed by AIM.

 

Step Therapy 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 existing specialty pharmacy medical step therapy review process. 

 

Inflectra is changing to preferred status effective July 1, 2021.

 

To access the Clinical Criteria information, click here.

 

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

Status

Drug(s)

HCPCS Codes

ING-CC-0062

Preferred

Inflectra

Q5103

ING-CC-0062

Preferred

Remicade

J1745

ING-CC-0062

Non-preferred

Avsola

Q5121

ING-CC-0062

Non-preferred

Renflexis

Q5104

 

1184-0621-PN-GA

 



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June 2021 Anthem Provider News - Georgia