Products & Programs PharmacyCommercialMay 1, 2024

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Designated specialty pharmacy network updates

As we previously communicated, Anthem requires providers who are not part of our designated specialty pharmacy network to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through our contracted medical specialty pharmacy.

Updates

Effective for dates of service on and after August 1, 2024, the following specialty pharmacy medications will be removed from the Designated Medical Specialty Pharmacy Drug List:

HCPCS

Description

Brand name

J0179

INJECTION, BROLUCIZUMAB-DBLL, 1 MG

BEOVU

J0202

INJECTION ALEMTUZUMAB 1 MG

LEMTRADA

J0256

INJ ALPHA 1-PROTASE INHIB NOS 10 MG (ARALAST, ZEMAIRA ONLY)

ARALAST/ZEMAIRA

J0257

INJ ALPHA 1 PROTEINASE INH 10 MG (GLASSIA)

GLASSIA

J0584

BUROSUMAB-TWZA

CRYSVITA

J0593

INJECTION LANADELUMAB-FLYO 1 MG

TAKHZYRO

J0596

INJ C1 ESTERASE INHIB RUCONEST 10 U

RUCONEST

J0597

INJ C1 ESTERASE INHIB BERINERT 10 U

BERINERT

J0598

INJ C1 ESTERASE INHIB CINRYZE 10 U

CINRYZE

J0599

INJ C-1 ESTERASE INHIBITOR 10 UNITS

HAEGARDA

J1555

INJECTION IMMUNE GLOBULIN 100 MG

CUVITRU

J1559

INJECTION IG HIZENTRA 100 MG

HIZENTRA

J1561

INJ IG NONLYOPHILIZED 500 MG

GAMUNEX-C GAMMAKED

J1566

INJ IG IV LYPHILIZED NOS 500 MG

GAMMAGARD S/D

J1568

INJ IG OCTOGAM IV NONLYO 500MG

OCTAGAM

J1569

INJ IG GAMMAGARD IV NONLYO 500 MG

GAMMAGARD

J1575

INJ IG/HYALURONIDASE 100 MG IG

HYQVIA

J1599

INJ IG IV NONLYOPHILIZED NOS 500 MG

IVIG NOC

J1786

INJECTION, IMIGLUCERASE, 10 UNITS

CEREZYME

J2323

INJECTION NATALIZUMAB 1 MG

TYSABRI

J2350

INJECTION OCRELIZUMAB 1 MG

OCREVUS

J2778

Injection, ranibizumab, 0.1 mg

LUCENTIS

J3060

INJECTION, TALIGLUCERASE ALFA, 10 UNITS

ELELYSO

J3385

INJ VELAGLUCERASE ALFA 100 UNITS

VPRIV

J7188

INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (OBIZUR), PER IU (CODE RE-USED BY CMS EFFECTIVE 1/1/16) (FOR BILLING PRIOR TO 1/1/16 USE C9399 OR J7199)

OBIZUR

J7311

Injection, fluocinolone acetonide, intravitreal implant 0.01 mg

RETISERT

J7313

Injection, fluocinolone acetonide, intravitreal implant 0.01 mg

ILUVIEN

J9042

INJECTION BRENTUXIMAB VEDOTIN 1 MG

ADCETRIS

J9316

PERTUZUMAB/TRASTUZUMAB/HYALURONIDASE-ZZXF, 10MG

PHESGO

To access the current Designated Medical Specialty Pharmacy Drug List, please visit anthem.com/provider, select Providers, select Forms and Guides (under the Provider Resources column), select your state, scroll down, and select Pharmacy in the Category drop down. The Designated Medical Specialty Pharmacy Drug List may be updated periodically by Anthem.

If you have questions or would like to discuss the terms and conditions to be included as a designated specialty pharmacy network provider, please contact your contract manager with Anthem. Thank you for your continued participation in the Anthem networks and the services you provide to our members. We are committed to a future of shared success.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CM-055913-24

PUBLICATIONS: May 2024 Provider Newsletter