*Change to Prior Authorization Requirements

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

 

Anthem’s medical specialty drug review team manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.

 

Important to note

Currently, your patients may be receiving these medications without prior authorization. Effective November 1, 2022, you may be required to request prior authorization review for your patients’ continued use of these medications.

 

By including National Drug Code (NDC) on your claim, you will 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, 2022, 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)

ING-CC-0072

Alymsys (bevacizumab-maly)

C9399, J3490, J3590

ING-CC-0107*

Alymsys (bevacizumab-maly)

C9399, J3490, J3590, J9999

ING-CC-0216*

Opdualag (nivolumab and relatlimab-rmbw)

C9399, J3490, J3590, J9999

ING-CC-0118*

Pluvicto (lutetium lu 177 vipivotide tetraxetan)

A9699

ING-CC-0002*

Releuko (filgrastim-ayow)

C9096

* Oncology use is managed by AIM.

 

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

 

Step therapy updates

Effective for dates of service on and after November 1, 2022, 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)

ING-CC-0107*

Non-preferred

Alymsys

C9399, J3490, J3590, J9999

ING-CC-0002*

Non-preferred

Releuko

C9096

*Oncology use is managed by AIM.

 

Courtesy notice

Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.

 

Quantity limit updates

Effective for dates of service on and after November 1, 2022, 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.

 

Clinical Criteria

Drug

HCPCS or CPT Code(s)

ING-CC-0072

Alymsys (bevacizumab-maly)

C9399, J3490, J3590

 

MULTI-BCBS-CM-003590-22

 



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August 2022 Anthem Provider News - Indiana