Material adverse change (MAC)

 

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our prior authorization (PA) review process.

 

Please note that the inclusion of a National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Clinical Criteria is available here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team.  Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.

 

Clinical Criteria

Drug

HCPCS or CPT Code

ING-CC-0096*

Rylaze(asparaginase erwinia chrysanthemi (recombinant)-rywn)

J3590

ING-CC-0167*

Ruxience

Q5119

ING-CC-0167*

Truxima

Q5115

ING-CC-0202

Saphnelo (anifrolumab-fnia)

J3490, J3590

ING-CC-0203

Ryplazim (plasminogen, human-tvmh)

J3490, J3590

      *Oncology use is managed by AIM

 

Step therapy updates

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process. 

    

Clinical Criteria

Status

Drug

HCPCS or CPT Code(s)

ING-CC-0075

Preferred

Rituxan

J9312

Riabni

Q5123

Non-preferred

Ruxience

Q5119

Truxima

Q5115

ING-CC-0167*

 

 

 

 

 

Preferred

(no PA or step therapy required)

Rituxan

J9312

Riabni

Q5123

Non-preferred

Ruxience

Q5119

Truxima

Q5115

      *Oncology use is managed by AIM

 

Quantity limit updates

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our quantity limit review process.

 

Clinical Criteria

Drug

HCPCS or CPT Code

ING-CC-0081

Crysvita (burosumab-twza)

J0584

ING-CC-0202

Saphnelo (anifrolumab-fnia)

J3490, J3590

 

1389-1121-PN-NV



Featured In:
November 2021 Anthem Provider News - Nevada