Prior authorization updates

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 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.

 

To access the clinical criteria information please click 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 or CPT Code(s)

Drug

*ING-CC-0127

J9999, C9399

Darzalex Faspro

* 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 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.

 

To access the clinical criteria information related to step therapy, please click here.

 

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

 

Clinical Criteria

Status

Drug(s)

HCPCS Code

ING-CC-0160

Non-preferred

Vyepti

J3032

ING-CC-0160

Non-preferred

Vyepti

C9063

ING-CC-0011

Non-preferred

Ocrevus

J2350

 

Correction to a prior authorization update

In the October 2020 edition of Provider News, we published a prior authorization update regarding clinical criteria ING-CC-0174 on the drug Kesimpta.

 

  • One HCPCS code has been added, J9302. This is the valid code for the drug Kesimpta.

 

743-1120-PN-NE

 



Featured In:
November 2020 Anthem Maine Provider News