Specialty pharmacy updates for Anthem Blue Cross and Blue Shield are listed below. These updates are effective for dates of service on and after February 1, 2022.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.

 

For Anthem 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.

 

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

 

Please note that inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

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 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.

 

Prior authorization updates

 

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Access our Clinical Criteria to view the complete information for these prior authorization updates.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0096**

J3590

Rylaze

ING-CC-0167**

Q5119

Ruxience

ING-CC-0167**

Q5115

Truxima

ING-CC-0202

J3490

J3590

Saphnelo

ING-CC-0203

J3490

J3590

Ryplazim

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Step therapy updates

 

Effective for dates of service on and after February 1, 2022, 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. 

 

Clinical Criteria

Status

HCPCS or CPT Code(s)

Drug

ING-CC-0075*

Preferred

J9312

Rituxan

Q5123

Riabni

Non-preferred

Q5119

Ruxience

Q5115

Truxima

ING-CC-0167**

 

Preferred

(no prior authorization or step therapy required)

J9312

Rituxan

Q5123

Riabni

Non-preferred

Q5119

Ruxience

Q5115

Truxima

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Quantity limit updates

 

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Access our Clinical Criteria to view the complete information for these quantity limit updates.

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

ING-CC-0081

J0584

Crysvita

ING-CC-0202

J3490

J3590

Saphnelo

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

1389-1121-PN-VA



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November 2021 Anthem Provider News - Virginia