Prior authorization updates

Effective for dates of service on and after April 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 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 Code

Drug

*ING-CC-0095

J9041

Velcade (Bortezomib)

*ING-CC-0095

J9044

Bortezomib

*ING-CC-0093

J9171

Docetaxel

*ING-CC-0181

J3490

Veklury

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

 

Step therapy update

 

Update on Ocrevus step therapy notification

Ocrevus will still be non-preferred as noted below, but please note that the step therapy criteria have been updated since the last publication. 

 

Effective for dates of service on and after February 1, 2021, 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.

 

Access the step therapy drug list here.  

 

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

Status

Drug

HCPCS Code

ING-CC-0011

Non-preferred

Ocrevus

J2350

 

Correction to a prior authorization update

In the November 2020 edition of Provider News, we published a correction to an article originally published in the October 2020 Provider News regarding clinical criteria ING-CC-0174 for the drug Kesimpta. Please disregard the November update and refer to the original article published in October 2020 for the correct HCPCS codes. For your convenience, we’ve also listed the correct HCPCS codes for Kesimpta below.

 

  • NOC codes J3490, J3590 and C9399 are valid codes for Kesimpta. Code J9302 is not a valid code for the drug Kesimpta.

 

915-0121-PN-NE



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January 2021 Anthem Maine Provider News