Prior authorization

Effective for dates of service on and after July 1, 2020, 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 NDC code on claims will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

To access the clinical criteria document information please click here.  

 

Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company, and are in italics in the grid below.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0003

C9399, J3490, J3590

Xembify

ING-CC-0062

J3590

Eticovo

ING-CC-0062

J3490

Hadlima

ING-CC-0072

J0179

Bevou

ING-CC-0152

J3490

Vyondys 53

ING-CC-0153

C9399, J3490, J3590

Adakveo

ING-CC-0154

C9399, J3490, J3590

Givlaari

* Non-oncology use is managed by Anthem’s medical specialty drug review team; oncology use is managed by AIM.

 

Step therapy updates

Effective for dates of service on and after July 1, 2020, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process.

 

Orencia will be the non-preferred agent for rheumatoid arthritis, polyarticular juvenile idiopathic arthritis and psoriatic arthritis. The table below will assist you in identifying the applicable preferred agents and clinical criteria.

 

To access the clinical criteria document information please click here.

 

Rheumatoid Arthritis (RA)

Clinical Criteria

HCPCS or CPT Code

Preferred Agents

Clinical Criteria

HCPCS or CPT Code

Non-Preferred Agent

ING-CC-0062

J1438

Enbrel

ING-CC-0078

J0129

Orencia

ING-CC-0062

J0135

Humira

ING-CC-0078

J0129

Orencia

ING-CC-0062

J3590

Simponi

ING-CC-0078

J0129

Orencia

ING-CC-0062

J1602

Simponi Aria

ING-CC-0078

J0129

Orencia

ING-CC-0062

J1745

Remicade

ING-CC-0078

J0129

Orencia

 

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

Clinical Criteria

HCPCS or CPT Code

Preferred Agents

Clinical Criteria

HCPCS or CPT Code

Non-Preferred Agent

ING-CC-0062

J1438

Enbrel

ING-CC-0078

J0129

Orencia

ING-CC-0062

J0135

Humira

ING-CC-0078

J0129

Orencia

 

Psoriatic Arthritis (PsA)

Clinical Criteria

HCPCS or CPT Code

Preferred Agents

Clinical Criteria

HCPCS or CPT Code

Non-Preferred Agent

ING-CC-0042

C9399

J3490

J3590

Cosentyx

ING-CC-0078

J0129

Orencia

ING-CC-0062

J1438

Enbrel

ING-CC-0078

J0129

Orencia

ING-CC-0062

J0135

Humira

ING-CC-0078

J0129

Orencia

ING-CC-0062

J3590

Simponi

ING-CC-0078

J0129

Orencia

ING-CC-0062

J1602

Simponi Aria

ING-CC-0078

J0129

Orencia

ING-CC-0062

J1745

Remicade

ING-CC-0078

J0129

Orencia

ING-CC-0063

J3357

Stelara

ING-CC-0078

J0129

Orencia



Featured In:
April 2020 Anthem New Hampshire Provider News