Products & Programs PharmacyCommercialApril 24, 2024

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

Specialty pharmacy updates — May 2024

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Medical Specialty Drug Review team of Anthem. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.

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 a 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 August 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 here view the complete information for these prior authorization updates.

Clinical Criteria

Drug

HCPCS or CPT® code(s)

CC-0259

Amtagvi (lifleucel)

J3490, J3590

CC-0258

iDoseTR (travoprost Implant)

J3490, J3590

CC-0260

Nexobrid (anacaulase-bcdb)

J7353

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 August 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 here view the complete information for these quantity limit updates.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0064

Arcalyst (rilonacept)

J2793

CC-0139

Evenity (romosozumab-aqqg)

J3111

CC-0258

iDoseTR (travoprost Implant)

J3490, J3590

CC-0064

Interleukin-1 Inhibitors (Ilaris)

J0638

CC-0057

Krystexxa (pegloticase)

J2507

CC-0260

Nexobrid (anacaulase-bcdb)

J7353

CC-0068

Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Saizenprep, Serostim, Zomacton, Zorbtive (somatropin drugs)

J2941

CC-0047

Trogarzo (ibalizumab-uiyk)

J1746

CC-0067

Tyvaso (treprostinil)

J7686

CC-0067

Ventavis (Iloprost)

Q4074

Site of care updates

Effective for dates of service on and after August 1, 2024, 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 here view the complete information for these site of care updates.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0252

Adzynma (ADAMTS13, recombinant-krhn)

C9167

CC-0001

Aranesp (darbepoetin alfa)

J0881

CC-0034

Berinert (c1 esterase inhibitor (human))

J0597

CC-0042

Bimzelx (bimekizumab-bkzx)

C9399, J3590

CC-0042

Cosentyx (secukinumab)

C9399, J3490, J3590

CC-0061

Eligard, Lupron Depot (leuprolide acetate)

J9217

CC-0001

Epogen, Procrit (epoetin alfa)

J0885

CC-0034

Kalbitor (ecallantide)

J1290

CC-0228

Leqembi (lecanemab)

J0174

CC-0061

Leuprolide Acetate Depot (Cipla) (leuprolide acetate)

J1954

CC-0061

Lupron Depot (leuprolide acetate)

J1950

CC-0111

Nplate (romiplostim)

J2796

CC-0050

Omvoh (mirikizumab-mrkz)

C9168

CC-0018

Pombiliti (cipaglucosidase alfa-atga)

J1203

CC-0001

Retacrit (epoetin alfa-epbx)

Q5106

CC-0235

Revcovi (elapegademase-lvlr)

C9399, J3590

CC-0256

Rivfloza (nedosiran)

J3490

CC-0034

Ruconest (recombinant c1esterase inhibitor)

J0596

CC-0203

Ryplazim (plasminogen, human-tvmh)

J2998

CC-0058

Sandostatin (octreotide)

J2354

CC-0058

Sandostatin LAR Depot (octreotide)

J2353

CC-0236

Signifor LAR (pasireotide)

J2502

CC-0066

Tofidence (tocilizumab-bavi)

Q5133

CC-0020

Tyruko (natalizumab-sztn)

Q5134

CC-0250

Veopoz (pozelimab-bbfg)

J9376

CC-0257

Wainua (eplontersen)

C9399, J3490

CC-0254

Zilbrysq (zilucoplan)

J3490

CC-0062

Zymfentra (infliximab-dyyb)

J3590


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-055424-24-CPN54800

PUBLICATIONS: May 2024 Provider Newsletter