CommercialMay 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
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