CommercialOctober 24, 2024
Change to Prior Authorization Requirements
Specialty pharmacy updates — November 2024
Specialty pharmacy updates for Anthem are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.
Note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of the national drug code (NDC) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Prior authorization updates
Effective for dates of service on or after February 1, 2025, 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) |
CC-0027* | Jubbonti; Wyost (denosumab-bbdz) | Q5136 |
CC-0002* | Nypozi (filgrastim-txid) | C9399, J3590 |
CC-0266* | Rytelo (imetelstat) | C9399, J9999 |
CC-0003* | Yimmugo (immune globulin intravenous, human–dira) | J3590 |
* Oncology use is managed by Carelon Medical Benefits Management.
Step therapy updates
Effective for dates of service on or after February 1, 2025, 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.
The current Orencia step therapy preferred product list under the medical benefit is being modified to include only those that are considered medical benefit drugs.
Access our Clinical Criteria to view the complete information for these step therapy updates.
Clinical Criteria | Status | Drug | HCPCS or CPT code(s) |
CC-0002 | Non-preferred | Nypozi | C9399, J3590 |
CC-0003 | Non-preferred | Yimmugo | J3590 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Site of care updates
Effective for dates of service on and after February 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC-0003 | Alyglo (immune globulin intravenous, human-stwk) | J1599 |
CC-0066 | Tyenne (tocilizumab-aazg) | Q5135 |
Quantity limit updates
Effective for dates of service on or after February 1, 2025, 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) |
CC-0266 | Rytelo (imetelstat) | C9399, J9999 |
CC-0027 | Jubbonti; Wyost (denosumab-bbdz) | Q5136 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-069728-24-CPN69536
PUBLICATIONS: November 2024 Provider Newsletter
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Visit https://providernews.anthem.com/indiana/articles/specialty-pharmacy-updates-november-2024-22663
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