Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialOctober 31, 2019

Pre-service clinical review and quantity limit updates for specialty pharmacy effective February 1, 2020

Pre-service clinical review updates

Effective for dates of service on and after February 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our pre-service review process.

 

Please note, inclusion of the NDC code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

To access the clinical criteria document information please click here.  

 

Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company, and are in italics.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0072

Q5118

Zirabev

ING-CC-0075

Q5115

Truxima

ING-CC-0075

J3490

Ruxience

ING-CC-0107

Q5118

Zirabev

*ING-CC-0142

J1930

Somatuline Depot

ING-CC-0143

C9399, J9999

Polivy

ING-CC-0144

J9313

Lumoxiti

ING-CC-0145

J9119

Libtayo

 

* Non-oncology use is managed by Anthem’s medical specialty drug review team; oncology use is managed by AIM.

 

Quantity limit updates

Effective January 31, 2020, clinical criteria document ING-CC-0136 drug dosage, frequency, and route of administration will be archived.

 

Effective for dates of service on and after February 1, 2020, pre-service clinical review of drug dosage, frequency and route of administration for the following specialty pharmacy codes from new or current clinical criteria will be based on the quantity limits established in the applicable clinical criteria document. The table below will assist you in identifying the applicable clinical criteria documents and corresponding HCPCS codes.

 

To access the clinical criteria document information please click here.  

 

Pre-service clinical review of these specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

 

Clinical Criteria Number

Clinical Criteria Name

Drug(s)

HCPCS Code(s)

ING-CC-0001

Erythropoiesis Stimulating Agents

Aranesp, Epogen, Mircera, Procrit, Retacrit

J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106

ING-CC-0003

Immunoglobulins

Asceniv, Bivigam, Carimune NF, Flebogamma DIF,  Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen

J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599

ING-CC-0007

Synagis (palivizumab)

Synagis

90378

ING-CC-0013

Mepsevii (vestronidase alfa)

Mepsevii

J3397

ING-CC-0018

Lumizyme (alglucosidase alfa)

Lumizyme

J0221

ING-CC-0021

Fabrazyme (agalsidase beta)

Fabrazyme  

J0180

ING-CC-0022

Vimizim (elosulfase alfa)

Vimizim 

J1322

ING-CC-0023

Naglazyme (galsulfase)

Naglazyme

J1458

ING-CC-0024

Elaprase (idursufase)

Elaprase 

J1743

ING-CC-0025

Aldurazyme (laronidase)

Aldurazyme

J1931

ING-CC-0028

Benlysta (belimumab)

Benlysta

J0490

ING-CC-0031

Intravitreal Corticosteroid Implants

Illuvien, Retisert, Ozurdex, Yutiq

J7311, J7312, J7313, J7314

ING-CC-0032

Botulinum Toxin

Botox, Xeomin, Dysport, Myobloc

J0585, J0586, J0587, J0588

ING-CC-0033

Xolair (omalizumab)

Xolair

J2357

ING-CC-0034

Agents for Hereditary Angioedema

Cinryze, Haegarda, Berinert, Berinert, Firazyr, Ruconest, Kalbitor, Takhzyro

J0596, J0597, J0598, J1290, J1744, J0599, J0593

ING-CC-0041

Complement Inhibitors

Soliris, Ultomiris

J1300, J1303

ING-CC-0043

Monoclonal Antibodies to Interleukin-5

Cinqair, Fasenra, Nucala

J0517, J2182, J2786

ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Tremfya, Ilumya

J1628, J3245

ING-CC-0051

Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

J1786, J3060, J3385

ING-CC-0058

Octreotide Agents

Sandostatin, Sandostatin LAR Depot

J2353, J2354

ING-CC-0061

GnRH Analogs for the treatment of non-oncologic indications

Lupron Depot/Depot-Ped

J1950, J9217

ING-CC-0062

Tumor Necrosis Factor Antagonists

Simponi Aria, Remicade, Inflectra, Renflexis, Ixifi, Humira, Enbrel, Cimzia

J1602, J1745, Q5103, Q5104, Q5109, J0135, J1438, J0717

ING-CC-0063

Stelara (ustekinumab)

Stelara 

J3357, J3358

ING-CC-0066

Monoclonal Antibodies to Interleukin-6

Actemra

J3262

ING-CC-0071

Entyvio (vedolizumab)

Entyvio

J3380

ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Avastin, Lucentis, Eylea, Macugen, Zirabev, Mvasi

J2503, C9257, J9035, J2778, J0178, Q5118, Q5017

ING-CC-0073

Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

J0256, J0257

ING-CC-0075

Rituxan (rituximab) for Non-Oncologic Indications

Rituxan, Truxima

J9312, Q5115

 

PUBLICATIONS: November 2019 Anthem Maine Provider News