Anthem Blue Cross and Blue Shield | CommercialMarch 1, 2019
Anthem expands specialty pharmacy prior authorization list
Effective for dates of service on and after June 1, 2019, the following specialty pharmacy codes from new clinical criteria or current clinical 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 along with 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.
This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).
The following clinical criteria will be effective June 1, 2019.
Clinical Criteria/Guideline |
HCPCS or CPT Code |
NDC Code |
Drug |
CG-DRUG-63 |
J3490 |
68152-0112-01 68152-0114-01 |
Khapzory™ |
ING-CC-0002 |
Q5110 |
00069-0291-10 00069-0291-01 00069-0292-01 00069-0292-10 |
Nivestym™ |
ING-CC-0002 |
J3490 |
68152-0112-01 68152-0114-01 |
Udenyca™ |
ING-CC-0003 |
J1599 |
68982-0820-01 68982-0820-02 68982-0820-03 68982-0820-04 68982-0820-05 68982-0820-06 68982-0820-81 68982-0820-82 68982-0820-83 68982-0820-84 68982-0820-85 68982-0820-86 |
Panzyga® |
ING-CC-0034 |
J3590 |
47783-0644-01 |
Takhzyro® |
ING-CC-0062 |
J3590 |
61314-0871-02 61314-0871-06 61314-0876-02 |
Hyrimoz™ |
ING-CC-0062 |
Q5109 |
00069-0811-01 |
Ixifi™ |
ING-CC-0065 |
J7192 |
00026-3942-25 00026-3944-25 00026-3946-25 00026-3948-25 00026-4942-01 00026-4944-01 00026-4946-01 00026-4948-01 |
Jivi® |
ING-CC-0074 |
J8655 |
69639-0102-01 |
Akynzeo® |
ING-CC-0077 |
C9399 J3590 |
68135-0058-90 68135-0673-40 68135-0673-45 68135-0756-20 |
Palynziq™ |
ING-CC-0081 |
J0584 |
69794-0102-01 69794-0203-01 69794-0304-01 |
Crysvita® |
ING-CC-0082 |
C9399 J3490 |
71336-1000-01 |
Onpattro™ |
Access the clinical criteria information.
PUBLICATIONS: March 2019 Anthem Provider Newsletter - Virginia
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