Prior authorization updates

 

Effective for dates of service on and after March 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.

 

To access the Clinical Criteria information, click here.  

 

Anthem Blue Cross and Blue Shield (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 shown in italics in the table below.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0179

J9999

Blenrep

ING-CC-0180

J3490, J3590, J9999

Monjuvi

ING-CC-0182

J1756

Venofer

ING-CC-0182

J2916

Ferrlecit

ING-CC-0182

J1750

Infed

ING-CC-0182

J1439

Injectafer

ING-CC-0182

Q0138

Feraheme

ING-CC-0182

J1437

Monoferric

* 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 March 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.

 

To access the Clinical Criteria information related to Step Therapy, 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 shown in italics in the table below.

 

Clinical Criteria

Status

Drug(s)

HCPCS Codes

ING-CC-0182

Preferred

Venofer

J1756

ING-CC-0182

Preferred

Ferrlecit

J2916

ING-CC-0182

Preferred

Infed

J1750

ING-CC-0182

Non-preferred

Injectafer

J1439

ING-CC-0182

Non-preferred

Feraheme

Q0138

ING-CC-0182

Non-preferred

Monoferric

J1437

ING-CC-0174

Non-preferred

Kesimpta

J3490 (NOC)

ING-CC-0174

Non-preferred

Kesimpta

J3590 (NOC)

ING-CC-0174

Non-preferred

Kesimpta

C9399 (NOC)

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

 

Effective on or after January 1, 2021, documentation may be required to support step therapy reviews.

 

846-1220-PN-CNT



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December 2020 Anthem Provider News - Ohio