*Notice of Material Amendment/Change to Contract (MAC)


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 Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.

 

Please note that 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 and after March 1, 2022, 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 prior authorization updates.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0018

J3490

J3590

C9399

Nexviazyme
(avalglucosidase alfa-ngpt)

*ING-CC-0034

J1744

Sajazir (icatibant)

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

 

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 March 1, 2022, 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

HCPCS or CPT Code(s)

Drug

*ING-CC-0018

J3490

J3590

C9399

Nexviazyme (avalglucosidase alfa-ngpt)

*ING-CC-0034

J1744

Sajazir (icatibant)

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

 

1440-1221-PN-CNT



Featured In:
December 2021 Anthem Provider News - Ohio