Federal Employee Program® specialty pharmacy clinical site-of-care prior authorization review

In the July 2019 edition of Provider News, we notified providers that certain Federal Employee Program® (FEP) plans (member IDs beginning with an “R”) utilize a prior approval process for specific specialty drugs and site of care. The prior approval process identifies members who meet appropriate site-of-care criteria and encourages ordering providers and members to consider using a lower level of care option for specific specialty drugs. There is no claim penalty for site of care under the current prior approval process. FEP will continue to use this process through December 31, 2019.

 

Effective with dates of service on or after January 1, 2020, Anthem FEP will implement a specialty pharmacy prior authorization review process for specific specialty drugs. The prior authorization review will include site-of-care criteria for outpatient hospital-based settings. As a result of this change, services provided on and after January 1, 2020, without a prior authorization will be denied.

 

FEP will continue to review Federal Employee Program medical policy criteria for medical necessity, and Anthem’s clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be utilized to review site-of-care criteria.

 

What’s new beginning with dates of service on or after January 1, 2020?

• Prior to administering the drugs noted below in any setting, a prior authorization must be completed in order to evaluate if the drug meets clinical criteria. Anthem FEP will begin accepting prior authorization requests on December 18, 2019 for dates of service on and after January 1, 2020. Request prior authorization review by calling the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at 800-860-2156.

 

• Outpatient hospital-based settings will require a site-of-care review for medical necessity as part of the prior authorization review.
  • A provider toolkit aligned to Anthem’s clinical guideline (CG-MED-83) will be given to providers requiring a site-of-care review, either by fax or e-review. For outpatient hospital settings that do not meet clinical criteria, a dedicated clinical team will work with you to identify alternate lower level of care sites that can safely administer the drug.
  • In the event that there are no infusion centers within 30 miles of the member’s place of residence, or there are no home infusion providers able to service the member’s residence, the hospital-based setting will be approved.

 

• If the prior authorization is denied for either the drug not meeting medical necessity or the site-of-care not meeting medical necessity, providers should follow the disputed claim/service process. To obtain the current process, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at 800-860-2156.

 

• Services provided on or after January 1, 2020, without prior authorization will result in a denial of claims payment.

 

Drugs requiring medical necessity and site-of-care review:

Drug	Code	FEP Medical Policy
Orencia	J0129	5.70.18
Benlysta	J0490	5.99.01
Privigen	J1459	5.20.03
Cuvitru	J1555	5.20.08
Bivigam	J1556	5.20.03
Gammaplex	J1557	5.20.03
Hizentra	J1559	5.20.08
Gamunex-c/Gammaked	J1561	5.20.03-IV
Gamunex-c/Gammaked	J1561	5.20.08-Subq
Carimune	J1566	5.20.03
Octagam	J1568	5.20.03
Gammagard liquid	J1569	5.20.03-IV
Gammagard liquid	J1569	5.20.08-Subq
Flebogamma	J1572	5.20.03
HyQvia	J1575	5.20.08
Panzyga	J1599	5.20.03
Simponi Aria	J1602	5.70.51
Remicade	J1745	5.50.02
Tysabri	J2323	5.60.13
Entyvio	J3380	5.50.12
Inflectra	Q5103	5.50.02
Renflexis	Q5104	5.50.02
Ixifi	Q5109	5.50.02

 

These changes apply to Anthem FEP members (member IDs beginning with an “R”) who are receiving the specialty drugs listed above through their medical benefits. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits. For more information, such as clinical criteria for specialty drugs and level of care, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at 800-860-2156.