Anthem expands specialty pharmacy prior authorization list

Effective for dates of service on and after September 1, 2019, the following specialty pharmacy codes from new or current clinical criteria or guideline will be included in our prior authorization review process.

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.  For Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc., pre-service 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.

 

The following clinical criteria or guideline will be effective September 1, 2019.

 

Clinical Criteria/Guideline	HCPCS or CPT Code(s)	NDC Code(s)	Drug
CG-DRUG-98	C9042 J9999	42367-0520-25	Belrapzo™
ING-CC-0088	C9399 J9999	72187-0401-01	Elzonris™
ING-CC-0087	C9399 J3590	72171-0501-01 72171-0505-01	Gamifant®
ING-CC-0041	C9399 J3590	25682-0022-01	Ultomiris™
ING-CC-0086	J3490	50458-0028-00 50458-0028-02 50458-0028-03	Spravato™