CommercialJune 1, 2021
June 2021 updates for specialty pharmacy are available
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 |
PUBLICATIONS: June 2021 Anthem Provider News - Georgia
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