Anthem 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 |
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 |
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 |
* 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
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