Products & Programs PharmacyCommercialNovember 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