Prior authorization updates for specialty pharmacy are available

Prior authorization updates

 

Effective for dates of service on and after March 1, 2021, 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 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), Anthem HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0179	J9999	Blenrep
ING-CC-0180	J3490, J3590, J9999	Monjuvi
ING-CC-0182	J1756	Venofer
ING-CC-0182	J2916	Ferrlecit
ING-CC-0182	J1750	Infed
ING-CC-0182	J1439	Injectafer
ING-CC-0182	Q0138	Feraheme
ING-CC-0182	J1437	Monoferric

* 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 March 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 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), Anthem HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

 

Clinical Criteria	Status	Drug(s)	HCPCS Codes
ING-CC-0182	Preferred	Venofer	J1756
ING-CC-0182	Preferred	Ferrlecit	J2916
ING-CC-0182	Preferred	Infed	J1750
ING-CC-0182	Non-preferred	Injectafer	J1439
ING-CC-0182	Non-preferred	Feraheme	Q0138
ING-CC-0182	Non-preferred	Monoferric	J1437
ING-CC-0174	Non-preferred	Kesimpta	J3490 (NOC)
ING-CC-0174	Non-preferred	Kesimpta	J3590 (NOC)
ING-CC-0174	Non-preferred	Kesimpta	C9399 (NOC)

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

 

Effective on or after January 1, 2021, documentation may be required to support step therapy reviews.

 

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