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 August 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+

Yusimry (adalimumab-aqvh)

J3590

ING-CC-0072+

Vabysmo (faricimab-svoa)

J3490, J3590

ING-CC-0210+

Enjaymo (sutimlimab-jome)

C9399, J3490, J3590, J9999

ING-CC-0211*+

Kimmtrak (tebentafusp-tebn)

C9399, J3490, J3590, J9999

ING-CC-0212+

Tezspire (tezepelumab-ekko)

C9399, J3590

ING-CC-0213+

Voxzogo (vosoritide)

C9399, J3490

*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 August 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-0072+

Non-Preferred

Vabysmo (faricimab-svoa)

J3490, J3590

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

 

Quantity limit updates

Effective for dates of service on and after August 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-0062+

Hulio (adalimumab-fkjp)

J3590

ING-CC-0062+

Ixifi (infliximab-qbtx)

Q5109

ING-CC-0062+

Yusimry (adalimumab-aqvh)

J3590

ING-CC-0072+

Vabysmo (faricimab-svoa)

J3490, J3590

ING-CC-0210+

Enjaymo (sutimlimab-jome)

C9399, J3490, J3590, J9999

ING-CC-0212+

Tezspire (tezepelumab-ekko)

C9399, J3590

ING-CC-0213+

Voxzogo (vosoritide)

C9399, J3490

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

 

2152-0522-PN-ME



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May 2022 Anthem Maine Provider News