Products & Programs PharmacyCommercialMay 1, 2023

Material adverse change

Specialty pharmacy updates - May 2023

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Anthem’s Medical Specialty Drug Review team. 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 prior authorization review for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Prior authorization updates

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

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

Clinical Criteria

Drug

HCPCS or CPT® code(s)

CC-0230

Adstiladrin (nadofaragene firadenovec-vncg)

J9999

CC-0062

Idacio (adalimumab-aacf)

J3490, J3590

CC-0231

Lamzede (velmanase alfa-tycv)

C9399, J3490

CC-0232*

Lunsumio (mosunetuzumab-axgb)

C9399, J3490, J3590, J9999

CC-0233

Rebyota (fecal microbiota, live – jslm)

C9399, J3490, J3590

CC-0234

Syfovre (pegcetacoplan)

C9399, J3490

CC-0116*

Vivimusta (bendamustine)

J9999

* Oncology use is managed by Carelon Medical Benefits Management, Inc.

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

Site of care updates

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our site of care review process.

Access our Clinical Criteria to view the complete information for these site of care updates.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0217

Amvuttra (vutrisiran)

J0225

CC-0194

Cabenuva (cabotegravir extended-release; rilpivirine extended-release)

J0741

CC-0003

Cutaquig (immune globulin)

J1551

CC-0210

Enjaymo (sutimlimab-jome)

J1302

CC-0018

Nexviazyme (avalglucosidase alfa-ngpt)

J0219

CC-0019

Reclast (zoledronic acid)

J3489

CC-0075

Riabni (rituximab-arrx)

Q5123

CC-0075

Ruxience (rituximab-pvvr)

Q5119

CC-0202

Saphnelo (anifrolumab-fnia)

J0491

CC-0212

Tezspire (tezepelumab-ekko)

J2356

CC-0075

Truxima (rituximab-abbs)

Q5115

CC-0207

Vyvgart (efgartigimod alfa-fcab)

J9332

CC-0220

Xenpozyme (olipudase alfa)

J0218

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be removed from our site of care review process.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0004

Acthar (corticotropin)

J0800

CC-0034

Berinert (C1 Esterase Inhibitor, Human)

J0597

CC-0034

Firazyr (icatibant)

J1744

CC-0154

Givlaari (givosiran)

J0223

CC-0034

Kalbitor (ecallantide)

J1290

CC-0013

Mepsevii (vestronidase alfa)

J3397

CC-0073

Prolastin-C (alpha-1 proteinase inhibitor)

J0256

CC-0156

Reblozyl (luspatercept)

J0896

CC-0034

Ruconest (C1 Esterase Inhibitor, Recombinant)

J0596

Quantity limit updates

Effective for dates of service on and after August 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-0230

Adstiladrin (nadofaragene firadenovec-vncg)

J9999

CC-0062

Idacio (adalimumab-aacf)

J3490, J3590

CC-0231

Lamzede (velmanase alfa-tycv)

C9399, J3490

CC-0233

Rebyota (fecal microbiota, live – jslm)

C9399, J3490, J3590

CC-0234

Syfovre (pegcetacoplan)

C9399, J3490

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

MULTI-BCBS-CM-022993-23-CPN22815

PUBLICATIONS: May 2023 Provider News