CommercialNovember 1, 2023
Specialty pharmacy updates
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 Carelon Medical Benefits Management, Inc., a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
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.
Prior authorization updates
Effective for dates of service on and after February 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
Clinical Criteria | Drug | HCPCS or CPT® code(s) |
CC-0247 | Beyfortus (nirsevimab) | J3490, J3590, J9999, C9399 |
CC-0207 | Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | J3490, C9399 |
CC-0072 | Eylea HD (aflibercept) | J3490, J3590 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on and after February 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) | |
CC-0247 | Beyfortus (nirsevimab) | J3490, J3590, J9999, C9399 | |
CC-0207 | Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | J3490, C9399 | |
CC-0072 | Eylea HD (aflibercept) | J3490, J3590 | |
Site of care updates
Effective for dates of service on and after February 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC-0065 | Altuviiio (antihemophilic factor (recombinant) | J7214 |
CC-0227 | Briumvi (ublituximab) | J2329 |
CC-0062 | Cimzia (certolizumab pegol) | J0717 |
CC-0050 | Skyrizi (risankizumab-rzaa) | J2327 |
CC-0229 | Sunlenca (lenacapavir) | J1961 |
Effective for dates of service on and after February 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be removed from our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC-0111 | Nplate (romiplostim) | J2796 |
CC-0007 | Synagis (palivizumab) | 90378 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
MULTI-BCBS-CM-041432-23-CPN41260
PUBLICATIONS: November 2023 Provider Newsletter
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