Prior authorization updates for specialty pharmacy are available (January 2021)

Prior authorization updates

Effective for dates of service on and after April 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	Markets Impacted
*ING-CC-0095	J9041	Velcade (Bortezomib)	CA, CT, ME, NH IN, KY, MO, NY, OH, WI, VA, GA
*ING-CC-0095	J9044	Bortezomib	CA, CT, ME, NH, IN, KY, MO, NY, OH, WI, VA, GA
*ING-CC-0093	J9171	Docetaxel	CT, ME, NH, IN, KY, MO, NY, , OH, WI, VA, GA
*ING-CC-0181	J3490	Veklury	ALL CSBD Markets

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

Step therapy updates

Update on Ocrevus Step Therapy Notification

Ocrevus will still be non-preferred as noted below, but please note that the step therapy criteria have been updated since the last publication. 

 

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 step therapy 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 shown in italics in the table below.

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

 

Correction to a prior authorization update

In the November 2020 edition of Provider News, we published a correction to an article originally published in the October 2020 Provider News regarding clinical criteria ING-CC-0174 for the drug Kesimpta. Please disregard the November update and refer to the original article published in October 2020 for the correct HCPCS codes. For your convenience, we’ve also listed the correct HCPCS codes for Kesimpta below.

• NOC codes J3490, J3590 and C9399 are valid codes for Kesimpta. Code J9302 is not a valid code for the drug Kesimpta.

 

 

915-0121-PN-GA