Products & Programs PharmacyCommercialOctober 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