Prior authorization updates

 

Effective for dates of service on and after August 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 your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access Clinical Criteria information please click here.

 

Anthem’s prior authorization 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 table below.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0156

J3490

Reblozyl

ING-CC-0156

J3590

Reblozyl

ING-CC-0156

C9399

Reblozyl

ING-CC-0157

C9399

Padcev

ING-CC-0157

J9309

Padcev

ING-CC-0158

J3490

Enhertu

ING-CC-0158

J3590

Enhertu

ING-CC-0158

C9399

Enhertu

ING-CC-0158

J9999

Enhertu

ING-CC-0159

J3490

Scenesse

ING-CC-0159

J3590

Scenesse

ING-CC-0155

J0207

Ethyol

ING-CC-0160

J3490

Vyepti

ING-CC-0160

J3590

Vyepti

*ING-CC-0002

J3590

Ziextenzo

*ING-CC-0002

C9399

Ziextenzo

ING-CC-0062

J3590

Avsola

ING-CC-0062

J3590

Abrilada

ING-CC-0062

C9399

Abrilada

ING-CC-0065

J7192

Esperoct

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

 

Site of care updates

 

Effective for dates of service on and after August 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization site of care review process.

 

To access the site of care drug list, please click here.

 

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0082

J0222

Onpattro

ING-CC-0043

J0517

Fasenra

ING-CC-0049

J1301

Radicava

ING-CC-0041

J1303

Ultomiris

ING-CC-0003

J1599

Asceniv

ING-CC-0047

J1746

Trogarzo

ING-CC-0050

J3245

Ilumya

ING-CC-0013

J3397

Mepsevii

ING-CC-0002

Q5110

Nivestym

ING-CC-0002

Q5111

Udenyca

 

Step therapy updates

 

Effective for dates of service on and after August 1, 2020, 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.

 

To access the step therapy drug list, please click here.

 

Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

 

Clinical Criteria

Status

Drug(s)

HCPCS Code(s)

ING-CC-0062

Non-preferred

Avsola

J3590

 

432-0520-PN-CNT



Featured In:
May 2020 Anthem Provider News - Ohio