CommercialJuly 1, 2019
Anthem Federal Employee Health Benefit Program® (FEP) PPO Members will now require prior approval for specific Specialty Drugs and Site of Care
Effective July 1, 2019, Anthem Federal Employee PPO members, (ID numbers beginning with an, ‘R’), aged 18 and older, and not Medicare Primary, will now need to have Prior Approval for the following medications:
List of medications by code
Code |
Procedure Description |
J0129 |
Abatacept injection (Orencia) |
J0490 |
Belimumab injection (Benlysta) |
J1459 |
Injection, immune globulin (Privigen) |
J1555 |
Injection, immune globulin (Cuvitru) |
J1556 |
Injection, immune globulin (Bivigam) |
J1557 |
Injection, immune globulin (Gammaplex) |
J1559 |
Injection, immune globulin (Hizentra) |
J1561 |
Injection, immune globulin (Gamunex-c/Gammaked) |
J1566 |
Injection, immune globulin (Carimune) |
J1568 |
Injection, immune globulin (Octagam) |
J1569 |
Injection, immune globulin (Gammagard liquid) |
J1572 |
Injection, immune globulin (Flebogamma) |
J1575 |
Injection, immune globulin/hyaluronidase (HyQvia) |
J1599 |
Injection, immune globulin (Panzyga) |
J1602 |
Golimumab IV (Simponi Aria) |
J1745 |
Infliximab not biosimilar (Remicade) |
J2323 |
Natalizumab injection (Tysabri) |
J3380 |
Vedolizumab Injection (Entyvio) |
Q5103 |
Infliximab dyyb biosimilar (Inflectra) |
Q5104 |
Infliximab abda biosimilar (Renflexis) |
Q5109 |
infliximab-qbtx, biosimilar (Ixifi) |
In addition to acquiring Prior Approval for the medication, the Outpatient Hospital Site of Care must also be approved. The Prior Approval process will identify members who meet the appropriate Anthem site of care criteria and who can safely receive their medication in a location other than an outpatient hospital, including the home.
Effective January 1, 2020 failure to receive Prior Approval for these medications may result in non-coverage of the medication and facility services.
To acquire Prior Approval please contact the Anthem Federal Employee Program Utilization Management Department at (800-860-2156).
PUBLICATIONS: July 2019 Anthem Provider News - Indiana
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