Prior authorization updates

 

Effective for dates of service on and after September 1, 2020, 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 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 please click here.  

 

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company, and are shown in italics in the table below.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0161

C9399

J3490

J3590

J9999

Sarclisa

*ING-CC-0058

J2354

Bynfezia

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

Oncology use is managed by AIM.

 

Step therapy updates

 

Effective for dates of service on and after September 1, 2020, 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.

 

To access the step therapy drug list, please click here.

 

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

 

Clinical Criteria

Status

Drug(s)

HCPCS Code(s)

ING-CC-0003

Non-preferred

Panzyga

J1599

ING-CC-0003

Non-preferred

Xembify

J3490

 

458-0620-KY.MO




Featured In:
June 2020 Anthem Provider News - Kentucky