Prior authorization updates

Effective for dates of service on and after December 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 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), and are shown in italics below.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0201

J9999

Rybrevant

* Oncology use is managed by AIM.

 

Quantity limit updates

Effective for dates of service on and after December 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), and are shown in italics below.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0050

J3490, J3590

Skyrizi

*ING-CC-0075

Q5123

Riabni

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

 

129-0921-PN-NE



Featured In:
September 2021 Maine Provider News