Prior authorization updates for specialty pharmacy effective October 1, 2021

Prior authorization updates

Effective for dates of service on and after October 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.  

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0195	J3490, J9999, C9399, J3590	Abecma

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

 

Step therapy updates

Effective for dates of service on and after October 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.

 

Visit our website to access the clinical criteria information.  

 

Prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria	Status	HCPCS or CPT Code	Drug
ING-CC-0020	Non-preferred	J2323	Tysabri

 

1221-0721-PN-NE