Products & Programs PharmacyCommercialNovember 18, 2024

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

Specialty pharmacy updates — December 2024

Specialty pharmacy updates for 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 Carelon Medical Benefits Management, Inc., a separate company.

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.

Prior authorization updates

Effective for dates of service on or after March 1, 2025, 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)

CC-0267

Ebglyss (lebrikizumab-lbkz)

C9399, J3590

CC-0072

Eylea (aflibercept) biosimilars:

Ahzantive (aflibercept-mrbb)
Enzeevu (aflibercept-abzv)
Opuviz (aflibercept-yszy)
Pavblu (aflibercept-ayyh)
Yesafili (aflibercept-jbvf)

C9399, J3590

CC-0268*

Lymphir (denileukin diftitox-cxdl)

C9399, J9999

CC-0269

Nemluvio (nemolizumab-ilto)

C9399, J3590

CC-0270*

Niktimvo (axatilmab-csfr)

C9399, J3590

CC-0011

Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq)

J3590

CC-0271

Tecelra (afamitresgene autoleucel)

C9399, J9999

* Oncology use is managed by Carelon Medical Benefits Management.

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

Step therapy updates

Effective for dates of service on or after March 1, 2025, 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.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria

Status

Drug

HCPCS or CPT code(s)

CC-0011

Non-preferred

Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq)

J3590

Quantity limit updates

Effective for dates of service on or after March 1, 2025, 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

Drug

HCPCS or CPT code(s)

CC-0267

Ebglyss (lebrikizumab-lbkz)

C9399, J3590

CC-0072

Eylea (aflibercept) biosimilars:

Ahzantive (aflibercept-mrbb)
Enzeevu (aflibercept-abzv)
Opuviz (aflibercept-yszy)
Pavblu (aflibercept-ayyh)
Yesafili (aflibercept-jbvf)

C9399, J3590

CC-0269

Nemluvio (nemolizumab-ilto)

C9399, J3590

CC-0011

Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq)

J3590

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

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.

MULTI-BCBS-CM-072458-24-CPN72383