Prior authorization updates for specialty pharmacy effective January 2021

Prior authorization updates

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

 

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

 

To access the clinical criteria information please click here.  

 

Prior authorization 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 shown in italics in the table below.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0170	J3590, C9399	Uplizna
ING-CC-0172	J3490, J3590, C9399	Viltepso
ING-CC-0173	J3490, J3590	Enspryng
ING-CC-0174	J3490, J3590, C9399	Kesimpta
ING-CC-0168	J3590, J9999, J3490	Tecartus
*ING-CC-0171	J3490, J3590, J9999	Zepzelca
*ING-CC-0169	J3490, J3590, J9999, C9399	Phesgo
*ING-CC-0175	J9015	Proleukin
*ING-CC-0176	J9032	Beleodaq
*ING-CC-0178	J9262	Synribo
*ING-CC-0177	J3304	Zilretta
ING-CC-0015	J3490	Milprosa Vaginal System
*ING-CC-0100	C9065	Istodax
ING-CC-0038	J3110	Forteo
*ING-CC-0002	J3590	Nyvepria

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

 

Step therapy updates

Effective for dates of service on and after January 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.

 

To access the clinical criteria information related to step therapy, please click here.

 

Prior authorization 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 shown in italics in the table below.

 

Clinical Criteria	Status	Drug	HCPCS Code
*ING-CC-0002	Preferred	Neulasta	J2505
*ING-CC-0002	Preferred	Udenyca	Q5111
*ING-CC-0002	Non-preferred	Fulphila	Q5108
*ING-CC-0002	Non-preferred	Ziextenzo	Q5120
*ING-CC-0002	Non-preferred	Nyvepria	J3590

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

 

676-1020-PN-NE