Prior authorization updates

Effective for dates of service on and after August 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.

 

Visit our website to access the clinical criteria information.  

 

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-0186

J3490, J3590, J9999

Margenza

*ING-CC-0187

J3490, J3590, J9999

Breyanzi

*ING-CC-0188

J3490, J3590

Imcivree

*ING-CC-0189

J3490, J3590, C9399

Amondys 45

*ING-CC-0190

J3490, J3590, C9399

Nulibry

**ING-CC-0094

J9304

Pemfexy

**ING-CC-0075

J3590, J9999, C9399

Riabni

* Non-oncology use is managed by the medical specialty drug review team.

**Oncology use is managed by AIM.

 

Prior authorization coding update – change in clinical criteria

Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.

 

Quantity limit updates

Effective for dates of service on and after August 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.

 

Visit our website to access the clinical criteria information.  

 

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 below.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0189

J3490, J3590, C9399

Amondys 45

*ING-CC-0190

J3490, J3590, C9399

Nulibry

* Non-oncology use is managed by the medical specialty drug review team.

1138-0521-PN-NE

 



Featured In:
May 2021 Anthem Maine Provider News