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

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

** Oncology use is managed by AIM.

 

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

*ING-CC-0095

J9041

Velcade (Bortezomib)

**ING-CC-0095

J9041

Velcade (Bortezomib)

*ING-CC-0095

J9044

Bortezomib

**ING-CC-0095

J9044

Bortezomib

*ING-CC-0093

J9171

Docetaxel

**ING-CC-0093

J9171

Docetaxel

*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.

 

1007-0321-PN-CNT



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March 2021 Anthem Provider News - Indiana