CommercialJune 2, 2025
Specialty pharmacy updates: June 2025
This article was updated on June 10, 2025 to correct the effective date from August 1, 2025 to September 1, 2025.
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 Carelon Medical Benefits Management, Inc., a separate company. Your patients may currently 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. Access our Clinical Criteria to view the complete information for these prior authorization updates.
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.
Prior authorization updates
Effective for dates of service on or after September 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC‑0149 | Alhemo (concizumab‑mtci) | C9399, J3590 |
CC‑0094 | Axtle (pemetrexed) | C9399, J9999 |
CC‑0279* | Datroway (datopotamab deruxtecan‑dlnk) | C9399, J9999 |
CC‑0280* | Grafapex (treosulfan) | C9399, J9999 |
CC‑0281* | Opdivo Qvantig (nivolumab hyaluronidase‑nvhy) | C9399, J9999 |
CC‑0063 | Steqeyma (ustekinumab‑stba) | C9399, J3590 |
CC‑0278* | Unloxcyt (cosibelimab‑ipdl) | C9399, J9999 |
* Oncology use is managed by Carelon Medical Benefits Management.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on or after September 1, 2025, 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‑0063 | Steqeyma (ustekinumab‑stba) | C9399, J9999 |
Step therapy updates
Effective for dates of service on or after September 1, 2025, 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.
Access our Clinical Criteria to view the complete information for these step therapy updates.
Clinical Criteria | Status | Drug | HCPCS or CPT code(s) |
CC‑0063 | Preferred | Selarsdi (ustekinumab‑aekn) | Q9998 |
CC‑0063 | Non‑preferred | Steqeyma (ustekinumab‑stba) | C9399, J3590 |
CC‑0063 | Non‑preferred | Yesintek (ustekinumab‑kfce) | C9399, J3590 |
Site of care updates
Effective for dates of service on or after September 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
Clinical Criteria | Drug | HCPCS or CPT Code(s) |
CC-0041 | Bkemv (eculizumab-aeeb) | Q5152 |
CC-0041 | Epysqli (eculizumab-aagh) | Q5151 |
CC-0149 | Hympavzi (marstacimab-hncq) | C9304 |
CC-0063 | Imuldosa (ustekinumab-srlf) | J3590 |
CC-0027 | Jubbonti (denosumab-bbdz) | Q5136 |
CC-0265 | Kisunla (donanemab-azbt) | J0175 |
CC-0011 | Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | J2351 |
CC-0063 | Otulfi (ustekinumab-aauz) | Q9999 |
CC-0041 | Piasky (crovalimab-akkz) | J1307 |
CC-0063 | Pyzchiva IV (ustekinumab-ttwe) | Q9997 |
CC-0063 | Selarsdi (ustekinumab-aekn) | Q9998 |
CC-0221 | Spevigo (spesolimab-sbzo) | J1747 |
CC-0050 | Tremfya IV (guselkumab) | J1628 |
CC-0063 | Wezlana IV (ustekinumab-auub) | Q5138 |
CC-0063 | Yesintek (ustekinumab-kfce) | J3590 |
CC-0003 | Yimmugo (immune globulin intravenous, human–dira) | J1599 |
Effective for dates of service on or after September 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be removed from our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
Clinical Criteria | Drug | HCPCS or CPT code(s) |
CC‑0062 | Zymfentra (infliximab‑dyyb) | J1748 |
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-083902-25, CPN83696
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