Effective for dates of service on or after December 1, 2019, the following drug codes from new or current medical policies or clinical UM guidelines will be included in our specialty pharmacy pre-service clinical review process.

Please note: inclusion of NDC code on claims will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM®), a separate company.  

 

Clinical Criteria

HCPCS or CPT Code(s)

NDC Code(s)

Drug

ING-CC-0003

J3490

J3590

C9399

68982-0810-01

68982-0810-02

68982-0810-03

68982-0810-04

68982-0810-05

68982-0810-06

Cutaquig®

ING-CC-0003

J1599

69800-0250-01

Asceniv™

ING-CC-0031

J3490

71879-0136-01

Yutiq™



Featured In:
September 2019 Anthem New Hampshire Provider News