Specialty pharmacy updates

Specialty pharmacy updates for Anthem are listed below.

 

Anthem’s medical specialty drug review team manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM), a separate company.

 

Important to note

Currently, your patients may be receiving these medications without prior authorization. Effective November 1, 2022, you may be required to request prior authorization review for your patients’ continued use of these medications.

 

By including the National Drug Code (NDC) on your claim, you will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Prior authorization updates

Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Access our Clinical Criteria to view the complete information for these prior authorization updates.

 

Clinical Criteria	Drug	HCPCS or CPT Code(s)
ING-CC-0072+	Alymsys (bevacizumab-maly)	C9399, J3490, J3590
ING-CC-0107*+	Alymsys (bevacizumab-maly)	C9399, J3490, J3590, J9999
ING-CC-0216*+	Opdualag (nivolumab and relatlimab-rmbw)	C9399, J3490, J3590, J9999
ING-CC-0118*+	Pluvicto (lutetium lu 177 vipivotide tetraxetan)	A9699
ING-CC-0002*+	Releuko (filgrastim-ayow)	C9096

* Oncology use is managed by AIM.

+ The applicable policy is attached in PDF format.

Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Step therapy updates

Effective for dates of service on and after November 1, 2022, 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 our Clinical Criteria to view the complete information for these step therapy updates.

 

Clinical Criteria	Status	Drug	HCPCS or CPT Code(s)
ING-CC-0002*	Non-preferred	Releuko	C9096
ING-CC-0107*	Non-preferred	Alymsys	C9399, J3490, J3590, J9999

*Oncology use is managed by AIM.

 

Courtesy notice

Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.

 

Quantity limit updates

Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Access our Clinical Criteria to view the complete information for these quantity limit updates.

 

Clinical Criteria	Drug	HCPCS or CPT Code(s)
ING-CC-0072	Alymsys (bevacizumab-maly)	C9399, J3490, J3590

 

MULTI-BCBS-CM-003590-22