Products & Programs PharmacyCommercialFebruary 22, 2024

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

Specialty pharmacy updates — March 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 medically 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 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

Update: In the January 2024 edition of Provider News, we announced prior authorizations for the following drugs would be effective April 1, 2024. Please be advised that the prior authorization effective date for the drugs listed below will be May 1, 2024.

Clinical Criteria

Drug

HCPCS or CPT® code(s)

CC-0248*

Elrexfio (elranatamab-bcmm)

C9165, J3590, J9999, C9399

CC-0018

Pombiliti (cipaglucosidase alfa-atga)

J3490, J3590

CC-0249*

Talvey (talquetamab-tgvs)

C9163, J3590, J9999, C9399

CC-0020

Tyruko (natalizumab-sztn)

J3490, J3590

CC-0250

Veopoz (pozelimab-bbfg)

C9399, J3590

CC-0251

Ycanth (cantharidin)

C9164, J3490

* Oncology use is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after June 1, 2024, 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-0107*

Avzivi (bevacizumab-tnjn)

J3490, J3590

CC-0255*

Loqtorzi (toripalimab-tpzi)

C9399, J3490, J3590

CC-0256

Rivfloza (nedosiran)

J3490

CC-0002*

Ryzneuta (efbemalenograstim alfa-vuxw)

J3490, J3590

CC-0257

Wainua (eplontersen)

C9399, J3490

* Oncology use is managed by Carelon Medical Benefits Management.

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 June 1, 2024, 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-0002

Ryzneuta (efbemalenograstim alfa-vuxw)

J3490, J3590

CC-0256

Rivfloza (nedosiran)

J3490

CC-0257

Wainua (eplontersen)

C9399, J3490

Step therapy updates

Effective for dates of service on and after June 1, 2024, 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-0107

Non-preferred

Avzivi (bevacizumab-tnjn)

J3490, J3590

CC-0002

Non-preferred

Ryzneuta (efbemalenograstim alfa-vuxw)

J3490, 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-050901-24-CPN50685

PUBLICATIONS: March 2024 Provider Newsletter