*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.

 

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.

 

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 June 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

Drug

HCPCS or CPT Code(s)

ING-CC-0062

Hulio

Ixifi

J3590

Q5109

*ING-CC-0205

Fyarro

J3490

J3590

*ING-CC-0206

Besremi

J3490

J3590

ING-CC-0207

Vyvgart

C9399

J3490

J3590

ING-CC-0208

Adbry

J3490

ING-CC-0209

Leqvio

J3490

ING-CC-0004

Purified Cortrophin Gel

J3490

J3590

* Oncology use is managed by AIM.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Site of care updates

 

Effective for dates of service on and after June 1, 2022, 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 prior authorization updates.

 

Clinical Criteria

Drug

HCPCS or CPT Code(s)

ING-CC-0004

Purified Cortrophin Gel

J3490

J3590

 

Step therapy 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 removed from our existing specialty pharmacy medical step therapy review process. 

 

Access our Clinical Criteria to view the complete information for these prior authorization updates.

 

Clinical Criteria

Drug

HCPCS or CPT Code(s)

ING-CC-0072

Mvasi

Zirabev

Q5107

Q5118

 

Quantity limit updates

 

Effective for dates of service on and after June 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 prior authorization updates.

 

Clinical Criteria

Drug

HCPCS or CPT Code(s)

*ING-CC-0206

Besremi

J3490

J3590

ING-CC-0207

Vyvgart

C9399

J3490

J3590

ING-CC-0208

Adbry

J3490

ING-CC-0209

Leqvio

J3490

*Oncology use is managed by AIM.

 

804-0322-PN-CNT



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March 2022 Anthem Provider News - Ohio