Virginia
Provider Communications
Specialty pharmacy updates - February 2023
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to submit a prior authorization for your patients’ continued use of these medications.
Including the National Drug Code (NDC) code on your claim may help expedite claim processing for 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 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.
Reminder: Clinical Criteria name change
In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged.
Prior authorization updates
Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.
|
Clinical Criteria |
Drug |
HCPCS or CPT® code(s) |
|
CC-0226*+ |
Elahere (mirvetuximab) |
J3590, J9999 |
|
CC-0223*+ |
Imjudo (tremelimumab-actl) |
J3490, J3590, J9999 |
|
CC-0224*+ |
Pedmark (sodium thiosulfate injection) |
J3490, J9999 |
|
CC-0222*+ |
Tecvayli (teclistamab-cqyv) |
J3490, J3590, J9999 |
|
CC-0225+ |
Tzield (teplizumab-mzwv) |
J3490, J3590 |
|
CC-0107*+ |
Vegzelma (bevacizumab-adcd) |
J3590, J9999 |
|
CC-0072+ |
Vegzelma (bevacizumab-adcd) |
J3590 |
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 May 1, 2023, 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 our Clinical Criteria to view the complete information for these step therapy updates.
Clinical Criteria CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent.
|
Clinical Criteria |
Status |
Drug |
HCPCS or CPT code(s) |
|
CC-0107*+ |
Non-preferred |
Alymsys |
C9142, J3490, J3590, J9999 |
|
CC-0107* |
Non-preferred |
Vegzelma |
J3590, J9999 |
|
CC-0107* |
Non-preferred |
Zirabev |
Q5118 |
|
CC-0107* |
Preferred |
Avastin |
J9035 |
|
CC-0107* |
Preferred |
Mvasi |
Q5107 |
Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status.
Quantity limit updates
Effective for dates of service on and after May 1, 2023, 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 |
Drug |
HCPCS or CPT code(s) |
|
CC-0225+ |
Tzield (teplizumab-mzwv) |
J3490, J3590 |
|
CC-0072+ |
Vegzelma (bevacizumab-adcd) |
J3590 |
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February 2023 Anthem Provider News - Virginia