Products & Programs PharmacyAnthem Blue Cross and Blue Shield | CommercialJanuary 31, 2023

Notice of material change/amendment to contract

Specialty pharmacy updates - February 2023

Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health®* (AIM), a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to submit a prior authorization for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing for drugs billed with a Not Otherwise Classified (NOC) code.

Reminder: Clinical Criteria name change

In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged.

Prior authorization updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Clinical Criteria

Drug

HCPCS or CPT® code(s)

CC-0226*+

Elahere (mirvetuximab)

J3590, J9999

CC-0223*+

Imjudo (tremelimumab-actl)

J3490, J3590, J9999

CC-0224*+

Pedmark (sodium thiosulfate injection)

J3490, J9999

CC-0222*+

Tecvayli (teclistamab-cqyv)

J3490, J3590, J9999

CC-0225+

Tzield (teplizumab-mzwv)

J3490, J3590

CC-0107*+

Vegzelma (bevacizumab-adcd)

J3590, J9999

CC-0072+

Vegzelma (bevacizumab-adcd)

J3590

* Oncology use is managed by AIM.

+ The applicable Clinical Criteria is attached to this article in PDF format. 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Step therapy updates

Effective for dates of service on and after May 1, 2023, 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. 

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent.

Clinical Criteria

Status

Drug

HCPCS or CPT code(s)

CC-0107*+

Non-preferred

Alymsys

C9142, J3490, J3590, J9999

CC-0107*

Non-preferred

Vegzelma

J3590, J9999

CC-0107*

Non-preferred

Zirabev

Q5118

CC-0107*

Preferred

Avastin

J9035

CC-0107*

Preferred

Mvasi

Q5107

* Oncology use is managed by AIM.

+ The applicable Clinical Criteria is attached to this article in PDF format. 

Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status.

Quantity limit updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0225+

Tzield (teplizumab-mzwv)

J3490, J3590

CC-0072+

Vegzelma (bevacizumab-adcd)

J3590

+ The applicable Clinical Criteria is attached to this article in PDF format.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of the health plan.

MEBCBS-CM-016918-23-CPN16708

ATTACHMENTS: Bevacizumab for non-ophthalmologic indications 1.25.23 CC-0107.pdf (pdf - 0.44mb), Elahere 1.3.23 CC-0226.pdf (pdf - 0.18mb), Imjudo 12.1.22 CC-0223.pdf (pdf - 0.15mb), Pedmark 12.1.22 CC-0224.pdf (pdf - 0.16mb), Tecvayli 12.1.22 CC-0222.pdf (pdf - 0.16mb), Tzield 12.5.22 CC-0225.pdf (pdf - 0.25mb), VEGF Inhibitors 1.25.23 CC-0072.pdf (pdf - 0.48mb)

PUBLICATIONS: February 2023 Provider Newsletter - Maine