Products & Programs PharmacyCommercialJuly 1, 2024

Correction: Specialty pharmacy updates — July 2024

This article was updated on October 9, 2024, to remove Ilumya as non-preferred from the step therapy requirements section below. Ilumya is not being added to the step therapy program at this time.

Specialty pharmacy updates for Anthem are listed below.

Anthem’s medical specialty drug review team manages prior authorization (PA) clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., 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 request PA review for your patients’ continued use of these medications.

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.

Prior authorization updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our PA review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

Clinical Criteria

Drug

HCPCS or CPT® Code(s)

CC-0003*

Alyglo (immune globulin intravenous, human-stwk)

J1599

CC-0062

Simlandi (adalimumab-ryvk)

J3590

CC-0261

Winrevair (sotatercept-csrk)

C9399, J3590

* Oncology use is managed by Carelon Medical Benefits Management.

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

Step therapy updates

Effective for dates of service on or after October 1, 2024, 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

Status

Drug

HCPCS or CPT Code(s)

CC-0003

Non-preferred

Alyglo (immune globulin intravenous, human-stwk)

J1599

CC-0062

Non-preferred

Cimzia (certolizumab pegol)

J0717

CC-0042

Non-preferred

Cosentyx intravenous (secukinumab)

C9399, J3490, J3590, C9166

CC-0050

Non-preferred

Omvoh (mirkizumab-mrkz)

C9168, J3590

Quantity limit updates

Effective for dates of service on or after October 1, 2024, 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-0062

Simlandi (adalimumab-ryvk)

J3590

CC-0261

Winrevair (sotatercept-csrk)

C9399, J3590

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-060687-24-CPN60563, MULTI-BCBS-CM-069897-24

PUBLICATIONS: July 2024 Provider Newsletter, November 2024 Provider Newsletter