Specialty pharmacy updates - August 2023

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.* 

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.

Including the National Drug Code (NDC) code on your claim may 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 November 1, 2023, 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.

* Oncology use is managed by Carelon Medical Benefits Management.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Step therapy updates

We are excited to announce the publication of a Medical Step Therapy Drug List. This list serves as an easy to access reference of the preferred and non-preferred products for each of the specialty pharmacy step therapy categories. The link to the pdf document is on the Clinical Criteria homepage.

Access our Clinical Criteria to view the Medical Step Therapy Drug List.

Quantity limit updates

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