Prior authorization and step therapy updates for specialty pharmacy

Prior authorization updates

Effective for dates of service on and after September 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
**ING-CC-0191	J3490, J9999, C9399	Pepaxto
**ING-CC-0192	J3490, C9399	Cosela
*ING-CC-0193	J3490, C9399	Evkeeza
*ING-CC-0194	J3490	Cabenuva
*ING-CC-0167	J9999, J3590, C9399	Riabni

* 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).

 

Visit our website to access the clinical criteria information.  

 

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

 

Step therapy updates

Effective for dates of service on and after July 1, 2021, 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. In addition, please note that Inflectra is changing to preferred status effective July 1, 2021.

 

Clinical Criteria	Preferred Status	Drug
ING-CC-0062	Preferred	Inflectra
ING-CC-0062	Preferred	Remicade
ING-CC-0062	Non-preferred	Avsola
ING-CC-0062	Non-preferred	Renflexis

 

Prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications is managed by AIM.

 

Visit our website to access the clinical criteria information.  

 

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

 

1184-0621-PN-NE