CommercialNovember 1, 2023
FEP® Specialty Pharmacy prior authorization list
Effective with dates of service on or after February 1, 2024, the following pharmacy codes will be included in the Federal Employee® (FEP) plans (member IDs beginning with an R) prior authorization review process for specialty drugs. As a result of this change, services provided on and after February 1, 2024, for these drugs without a prior authorization will be denied.
FEP will review the FEP medical policy criteria for medical necessity, and the clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be used to review site-of-care criteria.
What’s new beginning with dates of service on or after February 1, 2024, for the new drugs listed below?
- Prior to administering the drugs in any setting, a prior authorization must be completed to evaluate if the drugs meet clinical criteria. FEP will begin accepting prior authorization requests for these specialty drugs on January 15, 2024, for dates of service on and after February 1, 2024. Request prior authorization review by calling the FEP Service Benefit Plan at 800-860-2156.
- Outpatient hospital-based settings will require a site-of-care review for medical necessity as part of the prior authorization review. Hospital-based facilities contracted with Anthem Blue Cross and Blue Shield for lower drug and administration costs, non-hospital infusion clinics, provider offices, and home infusion providers will not require a site-of-care review:
- A provider toolkit aligned to the clinical guideline (CG-Med83) will be updated with these additional drugs and provided to providers requiring a site-of-care review, either by fax or e-review. For outpatient hospital settings that do not meet clinical criteria, a dedicated clinical team will work with you to identify alternate lower level of care sites that can safely administer the drug.
- If there are no infusion centers within 30 miles of the member’s place of residence, or there are no home infusion providers able to service the member’s residence, the hospital-based setting will be approved.
- If the prior authorization is denied for either the drugs not meeting medical necessity or the site-of-care not meeting medical necessity, providers should follow the disputed claim/service process. To obtain the current process, please contact the FEP Service Benefit Plan at 800-860-2156.
- Services provided on or after February 1, 2024, without prior authorization will result in a denial of claims payment.
Additional Drugs requiring medical necessity and site-of-care review as of February 1, 2024:
Drug | Code | FEP Medical Policy |
Avsola (infliximabe-axxq biosimilar) | Q5121 | 5.50.02 |
Cutaquig (immune globulin) | J1551 | 5.20.08 (Subq) |
Xembify (immune globulin) | J1558 | 5.20.08 (Subq) |
These changes apply to FEP members (member IDs beginning with an R) who are receiving the specialty drug listed above through their medical benefits. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits. For more information, such as clinical criteria for specialty drugs and level of care, please contact the FEP Service Benefit Plan at 800-860-2156.
MULTI-BCBS-CM-041501-23-CPN41102
PUBLICATIONS: November 2023 Provider Newsletter
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