October 2022 Specialty pharmacy updates (MAC)

Material adverse change

 

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_® (AIM), a separate company.

 

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.

 

Step therapy updates

 

Effective for dates of service on and after January 1, 2023, 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. 

 

Please note that infliximab agents are subject to step therapy today and this is to notify of the changes in the preferred and non-preferred products. Inflectra will become non-preferred and Avsola will become preferred as of January 1, 2023.

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Clinical Criteria	Status	Drug	HCPCS or CPT Code(s)
ING-CC-0062	Preferred	Avsola	Q5121
ING-CC-0062	Preferred	Infliximab Unbranded	J1745
ING-CC-0062	Preferred	Remicade	J1745
ING-CC-0062	Non-preferred	Inflectra	Q5103
ING-CC-0062	Non-preferred	Renflexis	Q5104

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

 

GABCBS-CM-007034-22-CPN6800