A new facility reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services will be implemented beginning with dates of service on or after May 1, 2021. We do not allow reimbursement for office evaluation and management services when reported on a CMS 1450 (UB-04) with revenue code 761 (treatment rooms). Modifiers will not override the edit.

 

For more information about this policy, visit the Reimbursement Policies page at anthem.com.  

 

975-0221-PN-NE

Prior authorization updates

Effective for dates of service on and after May 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 national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Visit our website to access the clinical criteria information.  

 

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

 

Clinical Criteria	HCPCS Code	Drug
*ING-CC-0183	J3590	Sogroya
*ING-CC-0001	J0886	Injection, epoetin alfa (Procrit/Epogen)
*ING-CC-0019	J3489	Reclast, Zometa

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

 

Quantity limit updates

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

 

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

 

Visit our website to access the clinical criteria information.  

 

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.

 

Clinical Criteria	HCPCS Code	Drug
*ING-CC-0019	J3489	Reclast, Zometa

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

 

979-0221-PN-NE

The following clinical criteria documents were endorsed at the November 20, 2020, Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective December 3, 2020

The following clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0119: Yervoy (ipilimumab)
• ING-CC-0125: Opdivo (nivolumab)

 

Revised clinical criteria effective December 9, 2020

The following clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0011: Ocrevus (ocrelizumab)
• ING-CC-0174: Kesimpta (ofatumumab)

 

Revised clinical criteria effective December 21, 2020

The following clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0003: Immunoglobulins
• ING-CC-0034: Hereditary Angioedema Agents
• ING-CC-0042: Monoclonal Antibodies to Interleukin-17
• ING-CC-0062: Tumor Necrosis Factor Antagonists
• ING-CC-0063: Stelara (ustekinumab)
• ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
• ING-CC-0072: Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
• ING-CC-0075: Rituximab Agents for Non-Oncologic Indications
• ING-CC-0121: Gazyva (obinutuzumab)
• ING-CC-0148: Agents for Hemophilia B
• ING-CC-0149: Select Clotting Agents for Bleeding Disorders

 

Reviewed clinical criteria effective December 21, 2020

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0001: Erythropoiesis Stimulating Agents
• ING-CC-0006: Hyaluronan Injections
• ING-CC-0014: Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• ING-CC-0040: Prialt (ziconotide)
• ING-CC-0047: Trogarzo (ibalizumab-uiyk)
• ING-CC-0049: Radicava (edaravone)
• ING-CC-0074: Akynzeo (fosnetupitant and palonosetron) for injection
• ING-CC-0107: Bevacizumab for Non-Ophthalmologic Indications
• ING-CC-0133: Aliqopa (copanlisib)
• ING-CC-0150: Kymriah (tisagenlecleucel)
• ING-CC-0151: Yescarta (axicabtagene ciloleucel)
• ING-CC-0155: Ethyol (amifostine)
• ING-CC-0166: Trastuzumab Agents Step Therapy
• ING-CC-0167: Rituximab Agents for Oncologic Indications Step Therapy
• ING-CC-0173: Enspryng (satralizumab-mwge)

 

New clinical criteria effective May 1, 2021

The following clinical criteria is new.

• ING-CC-0183: Sogroya (somapacitan-beco)

 

Revised clinical criteria effective May 1, 2021

The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

• ING-CC-0002: Colony Stimulating Factor Agents
• ING-CC-0003: Immunoglobulins
• ING-CC-0011: Ocrevus (ocrelizumab)
• ING-CC-0027: Denosumab Agents
• ING-CC-0034: Hereditary Angioedema Agents
• ING-CC-0039: GamaSTAN [immune globulin (human)]
• ING-CC-0041: Complement Inhibitors
• ING-CC-0042: Monoclonal Antibodies to Interleukin-17
• ING-CC-0048: Spinraza (nusinersen)
• ING-CC-0050: Monoclonal Antibodies to Interleukin-23
• ING-CC-0062: Tumor Necrosis Factor Antagonists
• ING-CC-0063: Stelara (ustekinumab)
• ING-CC-0064: Interleukin-1 Inhibitors
• ING-CC-0066: Monoclonal Antibodies to Interleukin-6
• ING-CC-0071: Entyvio (vedolizumab)
• ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy
• ING-CC-0078: Orencia (abatacept)
• ING-CC-0121: Gazyva (obinutuzumab)
• ING-CC-0148: Agents for Hemophilia B
• ING-CC-0174: Kesimpta (ofatumumab)

 

The following clinical criteria documents were endorsed at the December 18, 2020, Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective December 22, 2020

The following clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0124: Keytruda (pembrolizumab)

 

New clinical criteria effective December 22, 2020

The following clinical criteria is new.

• ING-CC-0184: Danyelza (naxitamab-gqgk)

 

Revised clinical criteria effective January 25, 2021

The following clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0002: Colony Stimulating Factor Agents
• ING-CC-0015: Infertility and HCG Agents
• ING-CC-0032: Botulinum Toxin
• ING-CC-0154: Givlaari (givosiran)

 

Reviewed clinical criteria effective January 25, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0079: Strensiq (Asfotase Alfa)
• ING-CC-0177: Zilretta (triamcinolone acetonide extended-release)

 

New clinical criteria effective May 1, 2021

The following clinical criteria is new.

• ING-CC-0185: Oxlumo (lumasiran)

 

Revised clinical criteria effective May 1, 2021

The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

• ING-CC-0032: Botulinum Toxin
• ING-CC-0154: Givlaari (givosiran)

 

959-0221-PN-NE

Effective with dates of service on and after April 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, we will update the drug lists that support our commercial health plans. Updates include changes to drug tiers and the removal of medications from the formulary. 

Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.

 

To help ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate. 

 

View a summary of changes in the attached PDF.  

 

IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.

 

981-0221-PN-NE

 

For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacyinformation. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).

 

To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.

 

FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.

 

977-0221-PN-NE