Prior authorization updates


Effective for dates of service on and after September 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization   process.


Please note, inclusion of National Drug Code (NDC) on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.


Access the clinical criteria information.

 

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0161

C9399

J3490

J3590

J9999

Sarclisa

*ING-CC-0058

J2354

Bynfezia

 

* Non-oncology use is managed by Anthem’s medical specialty drug review team; oncology use is managed by AIM.

 

Step therapy updates

 

Effective for dates of service on and after September 1, 2020, 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 the step therapy drug list.

 

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.  This would apply to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).”

 

Clinical Criteria

Status

Drug(s)

HCPCS Code(s)

ING-CC-0003

Non-preferred

Panzyga

J1599

ING-CC-0003

Non-preferred

Xembify

J3490

 

458-0620-PN-VA

 



Featured In:
June 2020 Anthem Provider News - Virginia