Prior authorization updates

Effective for dates of service on and after December 1, 2020, 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 NDC code on claims 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.

 

Clinical Criteria

HCPCS or CPT Code

Drug

ING-CC-0164

J3490

J9999

C9399

Jelmyto

ING-CC-0165

J3490

J3590

J9999

C9399

Trodelvy

ING-CC-0061

J1950

J3490

Fensolvi

 

 

Site of care updates

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization site of care review process.

 

To access the site of care drug list, 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 in italics.

 

Clinical Criteria

HCPCS or CPT Code

Drug

ING-CC-0153

J0791

Adakveo (crizanlizumab)

ING-CC-0139

J3111

Evenity (romosozumab)

ING-CC-0154

J0223

Givlaari (givosiran)

ING-CC-0156

J0896

Reblozyl (luspatercept)

ING-CC-0003

J1558

Xembify (immune globulin)

*ING-CC-0002

Q5120

Ziextenzo (pegfilgrastim-bmez)

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

 

Reminder: process for medical non-oncology specialty drug reviews

Please follow these steps to submit medical non-oncology specialty drug reviews:

 

Action

Contact

Submit a new prior authorization request for a medical specialty drug review 

Submit a reauthorization request for a medical specialty drug review previously performed by AIM

Call IngenioRx at 833-293-0659

or

Fax IngenioRx at 888-223-0550 

Inquire about an existing request (initially submitted to AIM or IngenioRx), peer-to-peer review, or reconsideration

Call IngenioRx at 833-293-0659

 

Please note:

 

  • AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.
  • Clinical criteria for medical non-oncology specialty drugs continue to reside on the Clinical Criteria webpage.
  • Post service clinical coverage reviews and grievance and appeals process and teams have not changed.

 

637-0920-PN-NE



Featured In:
September 2020 Anthem Maine Provider News