Prior authorization updates

Effective for dates of service on and after June 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, 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.

 

Visit our website to access the clinical criteria information.  

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0185

J3490, C9399

Oxlumo

**ING-CC-0184

J3490, J3590, J9999

Danyelza

*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).

 

Prior authorization update – change in effective date

Please note the change in date for the implementation of prior authorization for the injectable iron deficiency anemia products listed below. The effective date previously communicated was March 1, 2021.

 

Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, 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.

 

Visit our website to access the clinical criteria information.  

 

Clinical Criteria

HCPCS or CPT Code

Drug

*ING-CC-0182

J1756

Venofer

*ING-CC-0182

J2916

Ferrlecit

*ING-CC-0182

J1750

Infed

*ING-CC-0182

J1439

Injectafer

*ING-CC-0182

Q0138

Feraheme

*ING-CC-0182

J1437

Monoferric

*Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team.

 

Step therapy update – change in effective date

Please note the change in date for the implementation of step therapy for the injectable iron deficiency anemia products listed below. The effective date previously communicated was March 1, 2021.

 

Effective for dates of service on and after May 1, 2021, 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. 


Please note, 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.

 

Visit our website to access the clinical criteria information.  

 

Clinical Criteria

Status

Drug

HCPCS Codes

*ING-CC-0182

Preferred

Venofer

J1756

*ING-CC-0182

Preferred

Ferrlecit

J2916

*ING-CC-0182

Preferred

Infed

J1750

*ING-CC-0182

Non-preferred

Injectafer

J1439

*ING-CC-0182

Non-preferred

Feraheme

Q0138

*ING-CC-0182

Non-preferred

Monoferric

J1437

*Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by the medical specialty drug review team.

 

Prior authorization update - codes removed from prior authorization requirement

In a recent notification, we shared that effective April 1, 2021, the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization review process at this time.

 

Clinical Criteria

HCPCS or CPT Code

Drug

ING-CC-0095

J9041

Velcade (Bortezomib)

ING-CC-0095

J9044

Bortezomib

ING-CC-0093

J9171

Docetaxel

 

Medical specialty pharmacy update – removal of prior authorization requirement for certain drugs used to treat ocular conditions   

In an effort to help simplify care and support our providers, effective May 1, 2021, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions.

 

Drug

Code(s)

Code description

Avastin

C9257, J9035

Intravitreal bevacizumab

Mvasi

Q5107

Bevacizumab-awwb

Zirabev

Q5118

Bevacizumab-bvzr

 

1007-0321-PN-NE



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March 2021 Anthem New Hampshire Provider News