CommercialMay 31, 2023
Specialty pharmacy updates – June 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 Medical Specialty Drug Review team for Anthem. 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.
By including the National Drug Code (NDC) on your claim may help expedite processing of drugs billed with a not otherwise classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after September 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-0235 | Revcovi (elapegademase-lvlr) | C9399, J3590 |
CC-0236 | Signifor LAR (pasireotide) | J2502 |
CC-0065 | Altuviiio (antihemophilic factor (recombinant) | J3490, J3590 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on and after September 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-0236 | Signifor LAR (pasireotide) | J2502 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
MULTI-BCBS-CM-025135-23-CPN24856
PUBLICATIONS: June 2023 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/new-hampshire/articles/specialty-pharmacy-updates-june-2023-2-13555
Or scan this QR code with your phone