Prior authorization updates

 

Effective for dates of service on and after June 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 the Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.

 

Please note, inclusion of National Drug Code 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 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.

 

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-0185

J3490

C9399

Oxlumo

**ING-CC-0184

J3490

J3590

J9999

Danyelza

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

** Oncology use is managed by AIM.

 

Prior authorization update – change in effective date

 

Please note the change in date for the implementation of prior authorization for injectable iron deficiency anemia products.

 

The effective date has been changed to dates of service on and after May 1, 2021, for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our prior authorization review process. The previous effective date was March 1, 2021.

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, 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.

 

Please note, inclusion of National Drug Code code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code.

Access the Clinical Criteria information.


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), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*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.

 

Step therapy update – change in effective date

 

Please note the change in the effective date of step therapy for injectable iron deficiency anemia products.

 

The effective date has been changed to dates of service on and after May 1, 2021, for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our existing specialty pharmacy medical step therapy review process. The previous effective date was March 1, 2021.

 

Access the step therapy drug list.

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), HealthKeepers (HMO), POS AdvantageOne, and 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

 

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

 

Prior authorization update – change in code list

 

In a recent notification, we shared that effective April 1, 2021, the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization process at this time.

 

Access the Clinical Criteria information.

 

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), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0095

J9041

Velcade (Bortezomib)

**ING-CC-0095

J9041

Velcade (Bortezomib)

*ING-CC-0095

J9044

Bortezomib

**ING-CC-0095

J9044

Bortezomib

*ING-CC-0093

J9171

Docetaxel

**ING-CC-0093

J9171

Docetaxel

 

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

**Oncology use is managed by AIM.

 

Prior authorization update – Medical specialty pharmacy update

 

In an effort to simplify care and support our providers, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions, effective May 1, 2021.

 

Drug

Code

Code description

*Avastin

C9257

J9035

intravitreal bevacizumab

*Mvasi

Q5107

bevacizumab-awwb

*Zirabev

Q5118

bevacizumab-bvzr

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

 

1007-0321-PN-VA

 

 

 



Featured In:
March 2021 Anthem Provider News - Virginia