November 2020 prior authorization updates for specialty pharmacy are available

Prior authorization updates

Effective for dates of service on and after February 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 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 shown in italics in the table below.

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0127	J9999, C9399	Darzalex Faspro

* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.

 

Step therapy updates

Effective for dates of service on and after February 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.

 

To access the Clinical Criteria information related to Step Therapy, 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 shown in italics in the table below.

 

Clinical Criteria	Status	Drug(s)	HCPCS Codes
ING-CC-0160	Non-preferred	Vyepti	J3032
ING-CC-0160	Non-preferred	Vyepti	C9063
ING-CC-0011	Non-preferred	Ocrevus	J2350

* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.

 

Correction to a prior authorization update

In the October 2020 edition of Provider News, we published a prior authorization update regarding clinical criteria ING-CC-0174 on the drug Kesimpta.

• One HCPCS code has been added, J9302. This is the valid code for the drug Kesimpta.

 

743-1120-PN-GA