*Change to Prior Authorization Requirements


Prior authorization updates

 

Effective for dates of service on and after November 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.

 

Access the Clinical Criteria information 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-0196

J3490

J9999

J3590

Zynlonta

**ING-CC-0197

J3490

J3590

J9999

Jemperli

*ING-CC-0199

J3490

J3590

C9399

Empaveli

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Quantity limit updates

 

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit 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.

 

Access the Clinical Criteria information 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-0199

J3490

J3590

C9399

Empaveli

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

1271-0821-PN-CNT



Featured In:
August 2021 Anthem Provider News - Indiana