CommercialAugust 1, 2021
Updates for specialty pharmacy are available - August 2021*
*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.
PUBLICATIONS: August 2021 Anthem Provider News - Indiana
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