CommercialMay 1, 2020
Anthem prior authorization updates for specialty pharmacy are available
Effective for dates of service on and after August 1, 2020, 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 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.
Anthem’s 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 in italics.
Clinical Criteria |
HCPCS or CPT Code(s) |
Drug |
ING-CC-0156 |
J3490 |
Reblozyl |
ING-CC-0156 |
J3590 |
Reblozyl |
ING-CC-0156 |
C9399 |
Reblozyl |
ING-CC-0157 |
C9399 |
Padcev |
ING-CC-0157 |
J9309 |
Padcev |
ING-CC-0158 |
J3490 |
Enhertu |
ING-CC-0158 |
J3590 |
Enhertu |
ING-CC-0158 |
C9399 |
Enhertu |
ING-CC-0158 |
J9999 |
Enhertu |
ING-CC-0159 |
J3490 |
Scenesse |
ING-CC-0159 |
J3590 |
Scenesse |
ING-CC-0155 |
J0207 |
Ethyol |
ING-CC-0160 |
J3490 |
Vyepti |
ING-CC-0160 |
J3590 |
Vyepti |
*ING-CC-0002 |
J3590 |
Ziextenzo |
*ING-CC-0002 |
C9399 |
Ziextenzo |
ING-CC-0062 |
J3590 |
Avsola |
ING-CC-0062 |
J3590 |
Abrilada |
ING-CC-0062 |
C9399 |
Abrilada |
ING-CC-0065 |
J7192 |
Esperoct |
*Non-oncology use is managed byAnthem’s medical specialty drug review team; oncology use is managed by AIM.
Site of care updates
Effective for dates of service on and after August 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization site of care review process.
To access the site of care drug list, please click here.
Anthem’s 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 in italics.
Clinical Criteria |
HCPCS or CPT Code(s) |
Drug |
ING-CC-0082 |
J0222 |
Onpattro |
ING-CC-0043 |
J0517 |
Fasenra |
ING-CC-0049 |
J1301 |
Radicava |
ING-CC-0041 |
J1303 |
Ultomiris |
ING-CC-0003 |
J1599 |
Asceniv |
ING-CC-0047 |
J1746 |
Trogarzo |
ING-CC-0050 |
J3245 |
Ilumya |
ING-CC-0013 |
J3397 |
Mepsevii |
ING-CC-0002 |
Q5110 |
Nivestym |
ING-CC-0002 |
Q5111 |
Udenyca |
Step therapy updates
Effective for dates of service on and after August 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. Avsola will be added as a non-preferred agent to clinical critieria ING-CC-0062.
To access the site of care drug list, please click here.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.
Clinical Criteria |
Status |
Drug(s) |
HCPCS Code(s) |
ING-CC-0062 |
Non-preferred |
Avsola |
J3590 |
PUBLICATIONS: May 2020 Anthem Provider News - Georgia
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