Anthem prior authorization updates for specialty pharmacy are available

Prior authorization updates

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

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

Access the clinical criteria document information.   

 

For Anthem Blue Cross and Blue Shield and 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 prior authorization 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-0156	J3490	Reblozyl
ING-CC-0156	J3590	Reblozyl
ING-CC-0156	C9399	Reblozyl
ING-CC-0157	C9399	Padcev
ING-CC-0157	J9309	Padcev
ING-CC-0158	J3490	Enhertu
ING-CC-0158	J3590	Enhertu
ING-CC-0158	C9399	Enhertu
ING-CC-0158	J9999	Enhertu
ING-CC-0159	J3490	Scenesse
ING-CC-0159	J3590	Scenesse
ING-CC-0155	J0207	Ethyol
ING-CC-0160	J3490	Vyepti
ING-CC-0160	J3590	Vyepti
*ING-CC-0002	J3590	Ziextenzo
*ING-CC-0002	C9399	Ziextenzo
ING-CC-0062	J3590	Avsola
ING-CC-0062	J3590	Abrilada
ING-CC-0062	C9399	Abrilada
ING-CC-0065	J7192	Esperoct

* 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 August 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing pre-service site of care review process.

Access the site of care drug list.

 

For Anthem Blue Cross and Blue Shield and 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 prior authorization 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-0082	J0222	Onpattro
ING-CC-0043	J0517	Fasenra
ING-CC-0049	J1301	Radicava
ING-CC-0041	J1303	Ultomiris
ING-CC-0003	J1599	Asceniv
ING-CC-0047	J1746	Trogarzo
ING-CC-0050	J3245	Ilumya
ING-CC-0013	J3397	Mepsevii
ING-CC-0002	Q5110	Nivestym
ING-CC-0002	Q5111	Udenyca

 

Step therapy updates

Effective for dates of service on and after August 1, 2020, 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. Avsola will be added as a non-preferred agent to clinical critieria ING-CC-0062.

Access the step therapy drug list.

 

For Anthem Blue Cross and Blue Shield and 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 prior authorization 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 Code(s)
ING-CC-0062	Non-preferred	Avsola	J3590

 

432-0520-PN-VA