Site of care medical necessity reviews for long-acting colony-stimulating factors begin June 1, 2021
We are committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.
Effective with dates of service on or after June 1, 2021, medical necessity review of the site of care will be required for the following long-acting, colony-stimulating factors for oncology indications for Anthem Commercial plan members:
- Neulasta® & Neulasta Onpro® (pegfilgrastim)
- Fulphila® (pegfilgrastim-jmdb)
- Udenyca® (pegfilgrastim-cbqv)
- Ziextenzo® (pegfilgrastim-bmez)
- Nyvepria™ (pegfilgrastim-apgf)
The review will be administered by AIM Specialty Health® (AIM), a separate company.
AIM will evaluate the clinical information in the request to the CG-MED-083 Site of Care: Specialty Pharmaceuticals policy to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the clinical guideline and what clinical considerations are taken into account for determination, visit our Medical Policy and Clinical Guidelines webpage. You may contact AIM to request a peer-to-peer discussion before or after the determination.
The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.
Submit a request for review
Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:
- Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 866-714-1107, Monday - Friday, 8:00 a.m. - 5:00 p.m.
Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage and Medicare Supplemental plans. Providers can view prior authorization requirements for Anthem members on the Clinical Criteria webpage.
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the member’s ID card.
March 2021 Anthem Maine Provider News