Specialty pharmacy prior authorization list to be expanded effective December 1, 2019

Effective for dates of service on or after December 1, 2019, the following drug codes from new or current medical policies or clinical UM guidelines will be included in our specialty pharmacy pre-service clinical review process.

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

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

 

Clinical Criteria	HCPCS or CPT Code(s)	NDC Code(s)	Drug
ING-CC-0003	J3490 J3590 C9399	68982-0810-01 68982-0810-02 68982-0810-03 68982-0810-04 68982-0810-05 68982-0810-06	Cutaquig®
ING-CC-0003	J1599	69800-0250-01	Asceniv™
ING-CC-0031	J3490	71879-0136-01	Yutiq™