CommercialMarch 1, 2023
Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements
Specialty pharmacy updates for March 2023
Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by the Anthem Blue Cross and Blue Shield medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., 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 submit a prior authorization review for your patients’ continued use of these medications.
Including the national drug code on your claim may help expedite claim processing for drugs billed with a not otherwise classified code.
Prior authorization updates
Effective for dates of service on and after June 1, 2023, 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-0227 | Briumvi (ublituximab) | J3490, J3590 |
CC-0228 | Leqembi (lecanemab) | J3490, J3590 |
CC-0229 | Sunlenca (lenacapavir) | J3490, C9399 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after January 17, 2023, 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-0227 | Non-preferred | Briumvi (ublituximab) | J3490, J3590 |
Quantity limit updates
Effective for dates of service on and after June 1, 2023, 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-0227 | Briumvi (ublituximab) | J3490, J3590 |
CC-0229 | Sunlenca (lenacapavir) | J3490, C9399 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
MULTI-BCBS-CM-019364-23-CPN18451
PUBLICATIONS: March 2023 Anthem Provider News - Ohio
To view this article online:
Visit https://providernews.anthem.com/ohio/articles/specialty-pharmacy-updates-for-march-2023-4-12815
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