Specialty pharmacy updates - August 2023 

This article originally published with October 1, 2023 effective date in error.  This requirement will not go into effect until December 1, 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.,^* 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.

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 December 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Note: On April 6, 2023, the FDA announced its decision to withdraw approval of Makena and generic versions of Makena for reducing the risk of pre-term birth because these drugs are no longer shown to be effective.

Access our Clinical Criteria to view the complete information for these site of 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.