CommercialMarch 1, 2021
Updates for Specialty Pharmacy are available (March 2021)
Effective for dates of service on and after June 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, 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.
To access the Clinical Criteria information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria |
HCPCS or CPT Code(s) |
Drug |
*ING-CC-0185 |
J3490 C9399 |
Oxlumo |
**ING-CC-0184 |
J3490 J3590 J9999 |
Danyelza |
** Oncology use is managed by AIM.* Non-oncology use is managed by the medical specialty drug review team.
Prior authorization update – change in effective date
Please note the change in effective date of prior authorization for injectable iron deficiency anemia products listed below.
The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our prior authorization review process. The previous effective date was March 1, 2021.
Please note, 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.
To access the Clinical Criteria information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria |
HCPCS or CPT Code(s) |
Drug |
*ING-CC-0182 |
J1756 |
Venofer |
*ING-CC-0182 |
J2916 |
Ferrlecit |
*ING-CC-0182 |
J1750 |
Infed |
*ING-CC-0182 |
J1439 |
Injectafer |
*ING-CC-0182 |
Q0138 |
Feraheme |
*ING-CC-0182 |
J1437 |
Monoferric |
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Step therapy update – change in effective date
Please note the change in the effective date of step therapy for injectable iron deficiency anemia products.
The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our existing specialty pharmacy medical step therapy review process. The previous effective date was March 1, 2021.
To access the Clinical Criteria information with step therapy drug lists, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria |
Status |
Drug(s) |
HCPCS Codes |
*ING-CC-0182 |
Preferred |
Venofer |
J1756 |
*ING-CC-0182 |
Preferred |
Ferrlecit |
J2916 |
*ING-CC-0182 |
Preferred |
Infed |
J1750 |
*ING-CC-0182 |
Non-preferred |
Injectafer |
J1439 |
*ING-CC-0182 |
Non-preferred |
Feraheme |
Q0138 |
*ING-CC-0182 |
Non-preferred |
Monoferric |
J1437 |
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Prior authorization update – change in code list
In a recent notification, we shared that effective April 1, 2021 the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization process at this time.
To access the Clinical Criteria information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria |
HCPCS or CPT Code(s) |
Drug |
Markets Impacted |
*ING-CC-0095 |
J9041 |
Velcade (Bortezomib) |
CA, CT, ME, NH IN, KY, MO, NY, OH, WI, VA, GA |
**ING-CC-0095 |
J9041 |
Velcade (Bortezomib) |
CA, CT, ME, NH IN, KY, MO, NY, OH, WI, VA, GA |
*ING-CC-0095 |
J9044 |
Bortezomib |
CA, CT, ME, NH, IN, KY, MO, NY, OH, WI, VA, GA |
**ING-CC-0095 |
J9044 |
Bortezomib |
CA, CT, ME, NH, IN, KY, MO, NY, OH, WI, VA, GA |
*ING-CC-0093 |
J9171 |
Docetaxel |
CT, ME, NH, IN, KY, MO, NY, NE, OH, WI, VA, GA |
**ING-CC-0093 |
J9171 |
Docetaxel |
CT, ME, NH, IN, KY, MO, NY, NE, OH, WI, VA, GA |
*Non-oncology use is managed by Anthem’s medical specialty drug review team.
**Oncology use is managed by AIM.
Prior authorization update – medical specialty pharmacy update
In an effort to simplify care and support our providers, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions, effective May 1, 2021.
Drug |
Code |
Code description |
*Avastin |
C9257 J9035 |
intravitreal bevacizumab |
*Mvasi |
Q5107 |
bevacizumab-awwb |
*Zirabev |
Q5118 |
bevacizumab-bvzr |
*Non-oncology use is managed by Anthem’s medical specialty drug review team.
PUBLICATIONS: March 2021 Anthem Provider News - Georgia
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