Level of care pre-service clinical review drug list changes effective November 1, 2018

Effective for dates of service November 1, 2018, the following specialty pharmacy codes from new or current medical policies and/or clinical UM guidelines will be added to our existing level of care pre-service review process. 

 

Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM®), a separate company administering the program on behalf of Anthem, as applicable.

 

Level of care drug list additions

Clinical UM Guideline or Medical Policy	Drug Name	Drug Code(s)
CG-DRUG-78	HemlibraTM	Q9995
CG-DRUG-89	SublocadeTM	Q9991, Q9992
CG-DRUG-89	Probuphine®	J0570
CG-DRUG-05	Retacrit®	Q5106

 

In addition, effective immediately, the following specialty pharmacy codes from new or current medical policies and/ or clinical UM guidelines will be removed from our existing level of care pre-service review process. 

 

Level of care drug list deletions

Clinical UM Guideline or Medical Policy	Drug Name	Drug Code
CG-DRUG-100	Actimmune®	J9216
DRUG.00086	Increlex®	J2170
CG-DRUG-60	Firmagon®	J9155

 

View the Clinical Site of Care drug list and Clinical Site of Care pre-service clinical review FAQs for more information.