Prior authorization updates

 

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

 

The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with the Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.

Please note, inclusion of NDC code on your claim will help expedite claim processing 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 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 applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0038

J3110

Bonsity

ING-CC-0162

J3490

J3590

Tepezza

ING-CC-0163

J3490

C9399

Durysta

 

Step therapy updates

 

Effective for dates of service on and after October 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 Clinical Criteria information with step therapy(ies).

 

For Anthem Blue Cross and Blue Shield and 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 applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

Clinical Criteria

Status

Drug(s)

HCPCS Codes

ING-CC-0072

Preferred

Avastin

J9035, C9257

ING-CC-0072

Preferred

Mvasi

Q5107

ING-CC-0072

Preferred

Zirabev

Q5118

ING-CC-0072

Preferred

Eylea

J0178

ING-CC-0072

Non-preferred

Lucentis

J2778

ING-CC-0072

Non-preferred

Macugen

J2503

ING-CC-0072

Non-preferred

Beovu

J0179

 

CORRECTION: June 2020 step therapy update on clinical criteria ING-CC-0003:

 

Panzyga has been non-preferred for ING-CC 0003 since 2018.

 

In the June 2020 Provider News edition, we published information regarding Panzyga to be effective September 1, 2020. This was published in error.

 

540-0720-PN-VA



Featured In:
July 2020 Anthem Provider News - Virginia