Prior authorization updates

 

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Anthem in Virginia 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 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.

 

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 and are shown in italics in the table below.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0170

J3590, C9399

Uplizna

ING-CC-0172

J3490, J3590, C9399

Viltepso

ING-CC-0173

J3490, J3590

Enspryng

ING-CC-0174

J3490, J3590, C9399

Kesimpta

ING-CC-0168

J3590, J9999, J3490

Tecartus

*ING-CC-0171

J3490, J3590, J9999

Zepzelca

*ING-CC-0169

J3490, J3590, J9999, C9399

Phesgo

*ING-CC-0175

J9015

Proleukin

*ING-CC-0176

J9032

Beleodaq

*ING-CC-0178

J9262

Synribo

*ING-CC-0177

J3304

Zilretta

ING-CC-0015

J3490

Milprosa Vaginal System

*ING-CC-0100

C9065

Istodax

ING-CC-0038

J3110

Forteo

*ING-CC-0002

J3590

Nyvepria

 

* 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 January 1, 2021, 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 related to Step Therapy.


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 and are shown in italics in the table below.

 

This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Clinical Criteria

Status

Drug(s)

HCPCS Code(s)

*ING-CC-0002

Preferred

Neulasta

J2505

*ING-CC-0002

Preferred

Udenyca

Q5111

*ING-CC-0002

Non-preferred

Fulphila

Q5108

*ING-CC-0002

Non-preferred

Ziextenzo

Q5120

*ING-CC-0002

Non-preferred

Nyvepria

J3590

 

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

 

676-1020-PN-VA

 



Featured In:
October 2020 Anthem Provider News - Virginia