Prior authorization updates

 

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

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

 

Access the clinical criteria information.

 

For Anthem Blue Cross and Blue Shield and 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.

 

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-0164

J3490

J9999

C9399

Jelmyto

ING-CC-0165

J3490

J3590

J9999

C9399

Trodelvy

ING-CC-0061

J1950

J3490

Fensolvi

 


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

 

Site of care updates

 

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization site of care review process.

 

Access the site of care drug list.  

 

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.

 

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-0153

J0791

Adakveo (crizanlizumab)

ING-CC-0139

J3111

Evenity (romosozumab)

ING-CC-0154

J0223

Givlaari (givosiran)

ING-CC-0156

J0896

Reblozyl (luspatercept)

ING-CC-0003

J1558

Xembify (immune globulin)

*ING-CC-0002

Q5120

Ziextenzo (pegfilgrastim-bmez)

 

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

 

REMINDER: Process for Medical Non-Oncology Specialty Drug reviews

 

Please follow these steps to submit medical non-oncology specialty drug reviews:

 

Action

Contact

Submit a new prior authorization request for a medical specialty drug review 

Submit a re-authorization request for a medical specialty drug review previously performed by AIM

Call IngenioRx at 1-833-293-0659

or

Fax IngenioRx at 1-888-223-0550 

Inquire about an existing request (initially submitted to AIM or IngenioRx), peer-to-peer review, or reconsideration

Call IngenioRx

 

Please note:

 

  • AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.


  • Post-service clinical coverage reviews and grievance and appeals process and teams have not changed.

 637-0920-PN-VA



Featured In:
September 2020 Anthem Provider News - Virginia