CommercialApril 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
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