Products & Programs PharmacyCommercialAugust 26, 2024

Specialty pharmacy updates — September 2024

The specialty pharmacy updates for 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.

The inclusion of a 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 or after December 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-0264*

Anktiva (nogapendekin alfa inbekicept-pmln)

C9399, J9999

CC-0166*

Hercessi (trastuzumab-strf)

J3590

CC-0263*

Imdelltra (tarlatamab-dlle)

C9399, J9999

* Oncology use is managed by Carelon Medical Benefits Management.

Site of care updates

Update: In the May 2024 edition of Provider News, we announced the site of care review requirements for the following drugs would be effective August 1, 2024. Please be advised that the following drugs were not implemented to have SOC requirements added.

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

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0042

Bimzelx (bimekizumab-bkzx)

C9399, J3590

CC-0256

Rivfloza (nedosiran)

J3490

CC-0257

Wainua (eplontersen)

C9399, J3490

CC-0254

Zilbrysq (zilucoplan)

J3490

Step therapy updates

Effective for dates of service on or after December 1, 2024, 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.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria

Status

Drug

HCPCS or CPT code(s)

CC-0166

Non-Preferred

Hercessi (trastuzumab-strf)

J3590

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



Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-065565-24-CPN65398

PUBLICATIONS: September 2024 Provider Newsletter