Prior authorization updates

Effective for dates of service on and after July 1, 2020, 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 NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the clinical criteria document information please visit https://www11.anthem.com/pharmacyinformation/clinicalcriteria.html.

 

Anthem Blue Cross and Blue Shield (Anthem)’s 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 in italics.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0003

C9399

J3490

J3590

Xembify

ING-CC-0062

J3590

Eticovo

ING-CC-0062

J3490

Hadlima

ING-CC-0072

J0179

Bevou

ING-CC-0152

J3490

Vyondys 53

ING-CC-0153

C9399

J3490

J3590

Adakveo

ING-CC-0154

C9399

J3490

J3590

Givlaari

* 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 July 1, 2020, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process.

 

Orencia will be the non-preferred agent for rheumatoid arthritis, polyarticular juvenile idiopathic arthritis and psoriatic arthritis. The table below will assist you in identifying the applicable preferred agents and clinical criteria.

 

To access the clinical criteria document information please visit https://www11.anthem.com/pharmacyinformation/clinicalcriteria.html.

 

Rheumatoid Arthritis (RA)

 

Clinical Criteria

HCPCS or CPT Code

Preferred Agents

Clinical Criteria

HCPCS or CPT Code

Non-Preferred Agent

ING-CC-0062

J1438

Enbrel

ING-CC-0078

 

 

 

 

J0129

 

 

 

 

Orencia

 

 

 

 

ING-CC-0062

J0135

Humira

ING-CC-0062

J3590

Simponi

ING-CC-0062

J1602

Simponi Aria

ING-CC-0062

J1745

Remicade

 

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

 

Clinical Criteria

HCPCS or CPT Code

Preferred Agents

Clinical Criteria

HCPCS or CPT Code

Non-Preferred Agent

ING-CC-0062

J1438

Enbrel

ING-CC-0078

 

J0129

 

Orencia

 

ING-CC-0062

J0135

Humira

 

Psoriatic Arthritis (PsA)

 

Clinical Criteria

HCPCS or CPT Code

Preferred Agents

Clinical Criteria

HCPCS or CPT Code

Non-Preferred Agent

ING-CC-0042

C9399

J3490

J3590

Cosentyx

ING-CC-0078

 

 

 

 

 

 

J0129

 

 

 

 

 

 

Orencia

 

 

 

 

 

 

ING-CC-0062

J1438

Enbrel

ING-CC-0062

J0135

Humira

ING-CC-0062

J3590

Simponi

ING-CC-0062

J1602

Simponi Aria

ING-CC-0062

J1745

Remicade

ING-CC-0063

J3357

Stelara

 



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April 2020 Anthem Provider News - Missouri