Effective with dates of service on or after January 1, 2021, additional pharmacy codes will be included in the Federal Employee Program® (FEP®) plans (member IDs beginning with an “R”) prior authorization review process for specific specialty drugs. (See table below for a list of the additional drugs.) The prior authorization review includes review of site-of-care criteria for outpatient hospital-based settings. As a result of this change, on and after January 1, 2021, services provided for any of the additional drugs without a prior authorization will be denied.

 

FEP will continue to review FEP medical policy criteria for medical necessity, and Anthem’s clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be utilized to review site-of-care criteria.

 

What’s new beginning with dates of service on or after January 1, 2021 for the “new” drugs listed below?

  • Prior to administering the drugs in any setting, a prior authorization must be completed in order to evaluate if the drug meets clinical criteria. FEP will begin accepting prior authorization requests for these specialty drugs on December 14, 2020 for dates of service on and after January 1, 2021. Request prior authorization review by calling FEP at 800-860-2156.
  • Outpatient hospital-based settings will require a site-of-care review for medical necessity as part of the prior authorization review. Hospital-based facilities contracted with Anthem for lower drug and administration costs, non-hospital infusion clinics, provider offices, and home infusion providers will not require a site-of-care review.
    • A provider toolkit aligned to Anthem’s clinical guideline (CG-Med83) will be provided to providers requiring a site-of-care review, either by fax or e-review. For outpatient hospital settings that do not meet clinical criteria, a dedicated clinical team will work with you to identify alternate lower level of care sites that can safely administer the drug.
    • In the event that there are no infusion centers within 30 miles of the member’s place of residence, or there are no home infusion providers able to service the member’s residence, the hospital-based setting will be approved.
  • If the prior authorization is denied for either the drug not meeting medical necessity or the site-of-care not meeting medical necessity, providers should follow the disputed claim/service process. To obtain the current process, please contact FEP at 800-860-2156.
  • Services provided on or after January 1, 2021, without prior authorization will result in a denial of claims payment.

 

Additional drugs requiring medical necessity and site-of-care review as of January 1, 2021.

 

Drug

Code

FEP Medical Policy

Actemra®

J3262

5.70.12

Aralast®

J0256

5.45.09

Fabrazyme®

J0180

5.30.35

Fasenra®

J0517

5.45.07

Glassia®

J0257

5.45.09

Ilaris®

J0638

5.70.09

Nucala®

J2182

5.45.07

Ocrevus®

J2350

5.60.28

Prolastin®

J0256

5.45.09

Ultomiris®

J1303

5.85.33

Xolair®

J2357

5.45.02

Zemaira®

J0256

5.45.09

 

These changes apply to Anthem FEP members (member IDs beginning with an “R”) who are receiving the specialty drugs listed above through their medical benefits. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits. For more information, such as clinical criteria for specialty drugs and level of care, please contact FEP at 800-860-2156.

 

647-1020-PN-NE



Featured In:
October 2020 Anthem Maine Provider News