Specialty pharmacy updates for Anthem are listed below.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. 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. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

 

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.

 

Prior authorization updates

Effective for dates of service on and after June 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-0062

Hulio

Ixifi

J3590

Q5109

+*ING-CC-0205

Fyarro

J3490, J3590

+*ING-CC-0206

Besremi

J3490, J3590

+ING-CC-0207

Vyvgart

C9399, J3490, J3590

+ING-CC-0208

Adbry

J3490

+ING-CC-0209

Leqvio

J3490

+ING-CC-0004

Purified cortrophin gel

J3490, J3590

* Oncology use is managed by AIM.

+The applicable policy is attached to this article in PDF format.

 

Note: 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 March 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be removed from 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

Drug

HCPCS or CPT Code(s)

+ING-CC-0072

Mvasi

Zirabev

Q5107

Q5118

+The applicable policy is attached to this article in PDF format.


Quantity limit updates

Effective for dates of service on and after June 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-0206

Besremi

J3490, J3590

+ING-CC-0207

Vyvgart

C9399, J3490, J3590

+ING-CC-0208

Adbry

J3490

+ING-CC-0209

Leqvio

J3490

*Oncology use is managed by AIM.

+The applicable policy is attached to this article in PDF format.

 

804-0322-PN-ME



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March 2022 Anthem Maine Provider News