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.

 

846-1220-VA



Featured In:
December 2020 Anthem Provider News - Virginia