Anthem prior authorization updates for specialty pharmacy are available

Prior authorization updates

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

Please note, inclusion of National Drug Code (NDC) on your claim will shorten the claim processing time 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 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.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0161	C9399 J3490 J3590 J9999	Sarclisa
*ING-CC-0058	J2354	Bynfezia

 

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

 

Step therapy updates

 

Effective for dates of service on and after September 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.

 

Access the step therapy drug list.

 

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 would apply to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).”

 

Clinical Criteria	Status	Drug(s)	HCPCS Code(s)
ING-CC-0003	Non-preferred	Panzyga	J1599
ING-CC-0003	Non-preferred	Xembify	J3490

 

458-0620-PN-VA