Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (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 February 1, 2023, 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-0002*+

Fylnetra (pegfilgrastim-pbbk)

J3590

ING-CC-0002*

Rolvedon (eflapegrastim-xnst)

C9399, J3490, J3590

ING-CC-0002*

Stimufend (pegfilgrastim-fpgk)

C9399, J3490, J3590

ING-CC-0072+

Cimerli (ranibizumab-cqrn)

J3590

ING-CC-0220+

Xenpozyme (olipudase alfa)

C9399, J3490, J3590

ING-CC-0221+

Spevigo (spesolimab-sbzo)

C9399, J3490, J3590

* Oncology use is managed by AIM.

+ The applicable clinical criteria document is attached to this article in PDF format.

 

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

 

Site of care updates

Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.

 

Access our Clinical Criteria to view the complete information for these site of care updates.

 

Clinical Criteria

Drug

HCPCS or CPT code(s)

ING-CC-0065+

Advate (factor viii (antihemophilic factor, recombinant))

J7192

ING-CC-0065

Adynovate (factor vii)

J7207

ING-CC-0065

Afstyla (antihemophilic factor (recombinant) single chain))

J7210

ING-CC-0065

Alphanate (antihemophilic factor viii)

J7186

ING-CC-0065

Eloctate (recombinant antihemophilic factor)

J7205

ING-CC-0065

Esperoct (factor viii recombinant, glycopegylated)

J7204

ING-CC-0065

factor viii, anti-hemophilic factor (porcine)

J7191

ING-CC-0065

Hemlibra (emicizumab-kxwh)

J7170

ING-CC-0065

Hemofil M ((factor viii) human plasma-derived)

J7190

ING-CC-0065

Humate-P (antihemophilic factor viii)

J7187

ING-CC-0065

Jivi (factor viii, recombinant, pegylated-aucl)

J7208

ING-CC-0065

Koate DVI ((factor viii) human plasma-derived)

J7190

ING-CC-0065

Kogenate-FS (factor viii (antihemophilic factor, recombinant))

J7192

ING-CC-0065

Kovaltry (factor viii (antihemophilic factor, recombinant))

J7211

ING-CC-0065

Novoeight (factor viii (antihemophilic factor, recombinant))

J7182

ING-CC-0065

Nuwiq (factor viii (antihemophilic factor, recombinant))

J7209

ING-CC-0065

Obizur (antihemophilic factor viii (recombinant))

J7188

ING-CC-0065

Recombinate (factor viii (antihemophilic factor, recombinant))

J7192

ING-CC-0065

Vonvendi (von willebrand factor)

J7179

ING-CC-0065

Wilate (antihemophilic factor viii)

J7183

ING-CC-0065

Xyntha (factor viii (antihemophilic factor, recombinant))

J7185

ING-CC-0065

Xyntha Solofus (factor viii (antihemophilic factor, recombinant))

J7185

ING-CC-0148+

AlphaNine SD (coagulation factor ix (human))

J7193

ING-CC-0148

Alprolix (recombinant coagulation factor ix)

J7201

ING-CC-0148

Benefix (factor ix recombinant)

J7195

ING-CC-0148

Idelvion (factor ix)

J7202

ING-CC-0148

Ixinity (factor ix)

J7195

ING-CC-0148

Mononine (coagulation factor ix (human))

J7193

ING-CC-0148

Profilnine SD (factor ix complex human)

J7194

ING-CC-0148

Rebinyn (glycopegylated)

J7203

ING-CC-0148

Rixubis (factor ix recombinant)

J7200

ING-CC-0149+

Coagadex (factor x)

J7175

ING-CC-0149

Corifact (factor xiii concentrate (human))

J7180

ING-CC-0149

Feiba (anti-inhibitor coagulant complex)

J7198

ING-CC-0149

Fibryga (human fibrinogen)

J7177

ING-CC-0149

NovoSeven RT (factor viia recombinant)

J7189

ING-CC-0149

RiaSTAP (fibrinogen concentrate)

J7178

ING-CC-0149

Sevenfact (factor vlla recombinant)

J7212

ING-CC-0149

Tretten (coagulation factor xiii a-subunit (recombinant))

J7181

+ The applicable clinical criteria document is attached to this article in PDF format.

 

Step therapy updates

Effective for dates of service on and after February 1, 2023, 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. 

 

Clinical Criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro, and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long‑acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.

 

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

Fylnetra

J3590

ING-CC-0002*

Non-preferred

Rolvedon

C9399, J3490, J3590

ING-CC-0002*

Non-preferred

Stimufend

C9399, J3490, J3590

ING-CC-0002

Preferred

Neulasta

J2506

ING-CC-0002

Preferred

Neulasta OnPro

J2506

ING-CC-0002

Preferred

Udenyca

Q5111

ING-CC-0002

Non-preferred

Fulphila

Q5108

ING-CC-0002

Non-preferred

Nyvepria

Q5122

ING-CC-0002

Non-preferred

Ziextenzo

Q5120

*Oncology use is managed by AIM

 

This is a courtesy notice that there is a non-material change in the Clinical Criteria for Orencia ING-CC-0078.  The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s). 

 

Quantity limit updates

Effective for dates of service on and after February 1, 2023, 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-0017+

Xiaflex (collagenase clostridium histolyticum)

J0775

ING-CC-0072

Cimerli (ranibizumab-cqrn)

J3590

ING-CC-0182+

Feraheme (ferumoxytol)

Q0138

ING-CC-0182

Ferrlecit (ferric gluconate)

J2916

ING-CC-0182

Infed (iron dextran)

J1750

ING-CC-0182

Injectafer (ferric injection)

J1439

ING-CC-0182

Monoferric (ferric derisomaltose)

J1437

ING-CC-0182

Venofer (iron sucrose)

J1756

ING-CC-0220

Xenpozyme (olipudase alfa)

C9399, J3490, J3590

ING-CC-0221

Spevigo (spesolimab-sbzo)

C9399, J3490, J3590

+ The applicable clinical criteria document is attached to this article in PDF format.

 

MEBCBS-CM-010237-22-CPN9363

 



Featured In:
November 2022 Provider Newsletter - Maine